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Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or Coronavirus Disease 2019 (COVID-19); Understanding the Pandemic

COVID-19 was initially diagnosed in Wuhan China in December 2019, with several cases traced to the Huanan Seafood Market. Patients initially presented with unexplained cases of pneumonia for which the Chinese government took extra measures to control. Documented cases estimated an average incubation period of 5.2 days, and time to symptom manifestation of 2-14 days. The median time from symptom presentation to death is approximately 14 days. Studies suggest that disease may progress faster in the elderly, and those with chronic health conditions including Diabetes, Hypertension, and Cardiovascular disease have a high risk of contracting COVID-19. In China, COVID-19 disproportionately affects men more than women with a ratio of 3:1 (Sun, et al., 2020). This difference in male to female rates can be further understood by the virus’ mechanism of virulence.

According to Sun, et al., 2020, Angiotensin-Converting Enzyme 2 (ACE2) is the receptor for COVID-19. ACE2 is expressed on Type I and II alveolar cells in the normal lungs, and men have a higher number of ACE2 receptors than women. In the general population, Asian males have a higher number of ACE2 receptors than Asian females, and more so than Caucasians and African Americans. This explains the increased susceptibility of Asian males to COVID -19. The binding of COVID-19 to ACE2 receptors results in increased expression of ACE2 in the lungs, causing significant alveolar damage and subsequent respiratory insufficiency and failure.

Signs and symptoms of COVID-19 includes fever, runny nose, sore throat, cough, dyspnea (shortness of breath), fatigue, muscle aches, respiratory distress (difficulty breathing seen in severe cases), expectoration of sputum, hemoptysis (bloody sputum) seen in 5% of cases, and diarrhea in 3% of cases .

Affected patients are often hospitalized with initial laboratory results notable for leukopenia (low white blood cell count), lymphocytopenia (low lymphocyte count; subset of total white blood cell). Approximately 37% of patients may have abnormal liver enzymes, and 12% of patients may be diagnosed with Myocarditis (inflammation of the heart muscles) which may present with positive troponin on laboratory studies. Imaging studies preferably a chest Computed Tomography (CT) of affected individuals will reveal ground-glass opacities (GGO), interlobar septal thickening, and consolidations in bilateral lung fields. These CT findings are seen in > 95% of cases, and the severity of lung inflammation correlates with the severity clinical symptoms in affected patients (wu et al., 2020).

There is no confirmed treatment or vaccine for COVID-19. Therefore, the focus of treatment is symptomatic management of respiratory distress with supplemental oxygenation including mechanical ventilation when indicated, empiric antibiotics and antifungals to cover possible secondary infections, and appropriate infection control measures to prevent disease spread. Early identification, diagnosis, and supportive treatment can reduce morbidity and mortality from corona virus infection (Sun, et al., 2020).

Prevention measures include timely reporting of newly identified cases to appropriate health institutions and government agencies; Isolating affected individuals to avoid disease spread, avoiding interactions with affected populations, and if necessary, utilizing proper protective gear including mask, gloves, eye shield, and ensuring proper hand and environmental hygiene. In addition, it is necessary to administer supportive treatments to manage disease symptoms and decrease the risk of complications (CDC, 2020).

Most patients diagnosed with corona virus will recover from the disease, but some will have severe long-term complications particularly pulmonary fibrosis after recovery (Sun, et al., 2020). Therefore, measures to prevent deterioration of lung function, reduce lung inflammation and permanent damage should be implemented early, with ongoing research to improve long-term treatment options and outcomes.

Written by Dr. Idongesit Bassey

References

Sun, P., Lu, X., Xu, C., Sun, W., & Pan, B. (2020). Understanding of COVID-19 based on current evidence. Journal of Medical Virology, doi: 10.1002/jmv.25722 Wu, J., Wu, X., Zeng, W., Guo, D., Fang, Z., Chen, L., … Li., C. (2020). Chest CT findings in patients with corona virus disease 2019 and its relationship with clinical features. Investigative Radiology, doi: 10.1097/RLI.00000000000000670

A “New Nigeria,” What Will It Take?

Nigeria is a nation that is in desperate need of visionary leadership. For decades, we have depended on leaders who have no clear understanding of the depth of our problems as a nation, and lack the vision necessary to create impact. Our leaders make promises and fail because they are unwilling to undergo due process and carry out feasibility studies on how proposed projects can be implemented and sustained, as well as the supporting structures that must be in place to ensure long-term success.

We are left with a country that is broken from top to bottom, and a social service system that cannot meet the needs of its people. Our roads need improvement, our educational system needs to be updated to meet the demands of the 21sth century, and we need more creativity in our teaching methods to ensure that our graduates are well prepared for the work-force. We need quality improvements in our healthcare system, as well as some form of subsidized health services to ensure better outcomes for many Nigerians who would otherwise not access healthcare because of the cost.

We need leaders who understand that what we choose to ignore today will continue to cripple our nation, leaving our children and grandchildren to pay the price of our negligence. In the past, we accepted empty campaign promises along with all the gifts they distribute as a campaign tool to solicit our support. We have allowed tribalism and political affiliations direct how we vote. As a result, we have created recycled politicians who are well versed in sustaining a corrupt system, as long they are compensated and do not suffer the social ills experienced by the average Nigerian.

Thanks to the “Not Too Young to Run” policy, we now have several candidates with diverse backgrounds who may be able to turn the tide for Nigeria in 2019. We know that most people change once they have power and are corrupted by the existing influences within the system. However, we must remain hopeful that among the 2019 candidates, we may finally have leaders who can identify with Nigerians and will not bow to the wills of greedy political “God fathers.” We need leaders who are passionate about Nigeria and understand the importance of investing in our most valuable resource, the people.

We need leaders who understand the value of maintenance, as we have had multiple projects initiated in the past, while incoming leaders ignore projects by previous administrations and allow it to decay. This a waste of our nation’s resources, and we must find ways to improve and sustain projects that are making a positive impact in the society, while consolidating investments that no longer serve us. For example, if a governor builds a facility that was unable to meet the purpose for which it was built, the government should look to sell it to private institutions and utilize the funds for other valuable projects instead of allowing the building to decay.

We are desperate for leaders who are willing to establish standards and work hard to maintain it in all levels of public service. We can no longer continue to watch our leaders defect from one political party to another during the election season, with the hopes of building coalitions and continuing to perpetuate the status quo. We have had enough, and must join forces to make our voices heard in 2019. We need to consider young political parties like Alliance For New Nigeria whose vision is founded on bringing tangible change to Nigerians.

We need hope in our nation’s future and musts start now to reverse the ills of the past; to let go of corruption and misappropriation of public funds, and the mockery which we have allowed in our political offices. We must understand that public service is a call of destiny, and what we do with that opportunity can impact a generation. Therefore, we must not waste our political leadership opportunities on frivolous living and gross negligence, but we must commit our tenures to improving the lives of Nigerians and giving them a future that is brighter than yesterday.

Written By:

Dr. Idongesit Udoh Bassey

CHARACTERISTICS OF GOOD GOVERNANCE AND WHAT WE NEED TO CONSIDER WHEN CHOOSING LEADERSHIP IN 2019

Accountability: Accountability means that our public officials in all levels of government (local, state, federal) are answerable to each other and to the citizens. Therefore, they are required to account for what happens within the country, and intervene within the limits of their assigned position and responsibilities to ensure the safety and well-being of the people.
Transparent: Good governance calls for transparency between the government and the people. This is done through consistent provision of information that allows for clearer understanding of government processes and methods to monitor those processes. This helps to prevent corruption and promotes trust within the system
Responsive: A responsive government intervenes to maintain stability and avoid crisis by addressing the needs of all stakeholders. A responsive government creates and upholds policies to address loopholes within the system. For example, after the recent tanker fire incident on a Lagos bridge, a responsive government will implement and enforce laws that reduce the risk of that happening in the future.
Effective/Efficient: Good governance calls for effective and efficient processes. Recourses need to be maximized, and there must be a balance between the need for a project and its cost-effectiveness. For example, sharing the recently returned loot money to “poor Nigerian households” as reported in the news, will not improve the lives of Nigerians in any way. However, investing that money in education and healthcare may have a more sustained benefit for the nation.
Equitable/Inclusive: Good governance calls for equality and inclusion. This means that the rights of all citizens are valued, and the wellbeing of all members are prioritized in policy making and program allocations. No groups should be neglected based on tribe, culture, or religious differences.
Participatory: A good government allows for participation of its citizens in the development and implementation of policies because the citizens’ experiences and exposures can inform the government on the needs of the people, and where resources should be directed. Citizens should be able to access their immediate leaders at the local level, who then advocate for the concerns of his or her constituents at the national level.
Follows the rule of law: Good governance calls for a fair law system where no one is above the law and the rights of all citizens are protected.
Consensus-Oriented: A good government is conscious about the views of the larger population and seeks the best interest of all. It involves mediating different viewpoints and interests to arrive at a consensus that would benefit the entire group.
Strategic Vision: Good governance calls for strategic vision in determining short and long-term goals for the country, and what to do to achieve those goals within the designated time frames. It also requires understanding of competing variables including social, financial, cultural, and historical factors that may influence those goals, and developing methods to mitigate those factors.
Ubuntu: The word “ubuntu” is embodied in the words “compassion” and “humanity.” Our leaders need to stretch the limits of their compassion for our people, and look to alleviate suffering by collectively acting and making policies to improve the well-being of Nigerians.

Written By:

Dr. Idongesit Udoh Bassey

INTRODUCTION TO PRECLAMPSIA/ECLAMPSIA

Preeclampsia/eclampsia is one of the most common complications of pregnancy that affects approximately 5-10% of pregnant women and causes approximately 14% of maternal death worldwide. Available data from Nigeria points to preeclampsia/eclampsia affecting approximately 163/10000 deliveries, and causing several maternal deaths in the process (Danmusa, Coeytaux, Potts, & Wells, 2016). Preeclampsia/eclampsia treatment and management has evolved over the years, however more people need to be aware of this condition and seek appropriate care when suspected. This paper explains preeclampsia and its complications including eclampsia.

Preeclampsia

Preeclampsia describes a condition where a woman’s blood pressure becomes abnormally high after 20 weeks of pregnancy. With this condition, a woman who was previously normotensive (normal blood pressures) is diagnosed with hypertension and her urine when tested also shows the presence of excess protein (proteinuria). The condition can develop without any symptoms and is detected during routine pre-natal checkup. However, depending on the severity of the condition, a woman may present with symptoms including severe headaches, visual changes such as blurry vision and increased light sensitivity, excess protein in urine, low urine output, abdominal pain particularly near the ribcage and towards the right side, liver dysfunction on lab test, nausea and vomiting, shortness of breath, and sudden swelling/weight gain (edema) most noticeable in face and hands (Salam, Das, Ali, Bhaumik, & Lassi, 2015).

Diagnostic Criteria for Preeclampsia

Preeclampsia

Systolic Blood Pressure (SBP) > 140 mm Hg or Diastolic Blood Pressure (DBP) > 90 mm Hg in a pregnant woman at rest after 20 weeks of pregnancy
Proteinuria (Protein in urine) > 0.3g in 24-hour urine collection or 1+ protein in urine dipstick test

Severe Preeclampsia

Systolic Blood Pressure > 160 mm Hg or Diastolic Blood Pressure > 110 mm Hg on two occasions at least six hours apart in a woman at rest
Proteinuria > 5g in 24-hour urine collection or 3+ protein in urine dipstick test
Other presenting symptoms could include: low urine output (< 500ml per day), visual disturbances, right sided abdominal or epigastric pain, low platelets, difficulty breathing, edema, and abnormal liver function etc (Wagner, 2004).

The cause of preeclampsia is unknown. However, studies have shown that pregnancy causes growth of new blood vessels with placental development and implantation. These blood vessels are supposed to supply the placenta. In women with preeclampsia, these vessels are not well developed or functional, leading to impairment in placental blood flow and blood vessel spasms (vasopasm), which interferes with blood supply to multiple organs including the kidneys (Wagner, 2004). The sequela of this condition is intra-uterine growth restriction and severe hypertension for the mother. Some women who were diagnosed with hypertension before pregnancy can also have worsening hypertension and new protein in urine indicating the development of preeclampsia superimposed on prior hypertension. It is important to note that there are other types of hypertension during pregnancy that are different from preeclampsia, and these include Gestational Hypertension which describes high blood pressure first diagnosed during pregnancy without protein in urine, and Chronic Hypertension which classifies those patients who were already diagnosed with hypertension before pregnancy. There are many risk factors for preeclampsia, and they include:

History of hypertension
Family history of preeclampsia
First pregnancy (primigravity)
Teenage pregnancies or women > 35 years
Obesity
Multifetal pregnancies (pregnancy with multiples: twins, triplets etc)
In-vitro fertilization
Renal disease
Thrombophilia
Gestational diabetes
Systemic lupus erythematous

Complications of Preeclampsia

Preeclampsia causes several complications including intra-uterine growth restriction and low birth weight, preterm birth, placental infarcts and abruption, HELLP syndrome, and Eclampsia etc.

Intra-uterine Growth Restriction: Preeclampsia affects arteries that supply oxygenated blood to the placenta. Therefore, a decrease in oxygenated blood flow throw the placenta decreases blood supply to the baby resulting in slower growth, small for gestational age, and possible preterm birth.

Preterm Birth: Depending on the severity of preeclampsia, the baby may need to be delivered early to decrease the risk of intrauterine death or possible death of the mother. Unfortunately, premature delivery has its own problems as the baby’s lungs may be immature, resulting in respiratory distress and other complications after delivery.

Placental Abruption: As mentioned earlier, preeclampsia affects the blood vessels supplying oxygenated blood to the placenta. A decrease in oxygen supply to the placenta can cause placental infarcts and separation from the wall of the uterus. Placental separation is usually indicated by bleeding, and the degree of separation determines the severity of bleeding. However, placental separation requires immediate medical attention as the life of the baby and mother are at stake.

HELLP Syndrome (Hemolysis (destruction of red blood cells), Elevated Liver Enzymes, Low Platelets): This condition is one of the most severe end-organ complications of preeclampsia. It describes a set of clinical signs signaling a dire situation that is potentially fatal if not identified early and properly managed. HELLP syndrome is diagnosed with laboratory results which would point to red blood cell hemolysis, abnormal liver enzymes, and low platelets which result from platelet destruction. Immediate medical attention is needed to avoid fatal outcomes. Symptoms of HELLP syndrome include nausea and vomiting, headaches, and right upper abdominal pain (likely related to liver dysfunction).

Eclampsia: This describes the presence of grand-mal seizures or coma in a pregnant woman with no prior neurologic history or post-partum woman with preeclampsia. Eclampsia is one of the most dangerous complications of preeclampsia and necessitates emergent delivery of the baby to avoid death of both mother and child, as well as complex treatment and management to prevent further seizures in the immediate postpartum period. In some parts of Nigeria particularly northern Nigeria, Eclampsia contributed to approximately 33% of maternal deaths (Esike et al., 2017). Approximately 80% of cases of eclampsia occur in the 3^rd trimester, during labor, or within 48 hours after delivery. There has been a few reports of cases occurring even up to 23 days post-partum but these are extremely rare (Ross & Ramus, 2017).

Treatment and Management of Preeclampsia

Preeclampsia has no direct cure except delivery of the baby. Depending on gestational age of the fetus, the mother may be managed primarily with anti-hypertensives (medications to control blood pressure) to allow time for adequate fetal development. Arising complications including liver dysfunction are also monitored closely, and she is followed up more frequently by the obstetrician to assess need for emergent delivery. Apart from anti-hypertensives such as Labetalol and Hydralazine used to control blood pressure throughout pregnancy, Magnesium Sulfate has become a must in the management of women with preeclampsia. The medication is primarily used during labor and in the post-partum period to reduce the risk of seizures in women with preeclampsia, and to treat seizures in those who have already developed eclampsia. The use of magnesium sulfate has been shown to reduce the risk of eclampsia by 58% and mortality by up to 45%. The value of magnesium sulfate cannot be understated, and in 2007 the MacArthur Foundation began to fund programs to improve availability of Magnesium sulfate in Nigerian healthcare centers, as part of an initiative to reduce maternal mortality (Danmusa et al., 2016).

As stated earlier, the only cure for preeclampsia is delivery of the baby. However, several factors influence the timing at which the baby is delivered, and the gestational age and maternal/fetal well-being are primary considerations. Most healthcare providers will focus on blood pressure control and symptom management to allow time for fetal development, and carry out emergent delivery if the fetal or maternal well-being is severely compromised. Factors influencing timing of emergent delivery include severe intrauterine growth restriction, non-assuring fetal vital signs, deficiency in amniotic fluid (Oligohydramnios), platelet counts < 100,000, worsening liver function, suspected placental abruption, and eclampsia etc. Once the baby is delivered, the woman must be monitored closely with proper treatment to ensure recovery from the complications that developed over the course of pregnancy.

Till date, there is no available information on ways to prevent preeclampsia. Therefore, it is imperative for healthcare providers to educate pregnant women and carryout timely assessments and tests once they present with symptoms suspicious for preeclampsia. In addition, there is need for more public education on this condition, as public awareness can possibly improve health seeking behaviors and encourage pregnant women in places like Nigeria to obtain pre-natal healthcare from skilled healthcare providers, learn to monitor themselves for signs of complications, and report immediately to their obstetricians if any of these arises. With such concerted efforts, we stand a chance of reducing the rates of maternal and perinatal mortality in Nigeria.

Written by Dr. Idongesit Udoh Bassey

References

Danmusa, S., Coeytaux, F., Potts, J., & Wells, E. (2016). Scale-up of magnesium sulfate for treatment of pre-eclampsia and eclampsia in Nigeria. International Journal of Gynecology and Obstetrics, 134, 233-236. doi: http://dx.doi.org/10.1016/j.ijgo.2016.06.001

Esike, C. O. U., Chukwuemeka, U. I., Anozie, O. B., Eze, J. N., Aluka, O. C., & twomney, D., E. (2017). Eclampsia in rural Nigeria: the unmitigating catastrophe. Annals of African Medicine, 16(4), 175-180.

Ross, M. G. & Ramus, R. M. (2017). Eclampsia. Retrieved from https://emedicine.medscape.com/article/253960-overview.

Wagner, L. K. (2004). Diagnosis and management of preeclampsia. American Family Physician, 70(12), 2317 – 2324.

DIABETES MELLITUS IN NIGERIA

Diabetes mellitus (DM) is a chronic disease characterized by glucose intolerance of varying degrees, resulting in high blood glucose levels. Uncontrolled diabetes causes progressive and chronic damage to blood vessels and multiple organs, leading to further complications and increasing morbidity and mortality. More than 3 million Nigerians have diabetes, but a significant number of affected persons are not aware, and are diagnosed incidentally or after presenting with complications from the disease (Jackson, Adibe, Okonta, & Ukwe, 2014).

Numerically, diabetes is defined as fasting blood glucose (8 hours without eating) > 126 mg/dl, or random blood glucose checked at anytime > 200 mg/dl. Some people have impaired glucose tolerance or pre-diabetes, which is signaled by fasting blood glucose of 100-125 mg/dl. This last group of individuals could be targeted for preventative intervention to avoid progression to diabetes mellitus (Oguoma et al., 2017). Diabetes presents with several symptoms including excessive thirst (Polydipsia), excessive hunger (polyphagia), excessive urination (polyuria), dry mouth, nausea and vomiting, abdominal pain, weight loss, weakness, blurred vision, and frequent infections of the urinary tract and skin. There are two major types of diabetes, namely Type 1 and Type 2, and there are other transient forms of diabetes, including Gestational (pregnancy) diabetes. These three will be discussed in this article.

Type 1 Diabetes Mellitus

Type 1 diabetes is usually seen in children and young adults, and is sometimes referred to as Juvenile diabetes. It is characterized by high blood glucose levels and inability to metabolize glucose because of absolute insulin deficiency. Insulin is produced by the beta cells of the pancreas, but in these people, the beta cells are destroyed by an autoimmune attack, causing them to become non-functional and unable to produce insulin. Insulin helps remove glucose from the blood and into cells for use. Therefore, persons with Type 1 diabetes lack the ability to utilize glucose, leading to several symptoms which may be reported at time of diagnosis (Katsarou et al., 2017). These symptoms include:

Diabetic ketoacidosis (DKA): This is a condition which results from inability of the body to utilize available glucose for metabolic processes, so it breaks down fat into fatty acids and causes the liver to release stored glucose in attempt to provide fuel for the body. However, the body cannot utilize the extra glucose released, acid and the byproduct of fat breakdown known as ketones build up in the body, leading to a condition known as ketoacidosis. Ketoacidosis usually presents with several symptoms including fruity breath smell, confusion, abdominal pain, as well as labored and rapid breathing as the body attempts to compensate for acidosis. This condition is life threatening and requires hospitalization and management in the intensive care unit (Katsarou et al., 2017).

Dehydration: High blood glucose levels results in increased urine output because the body excretes excess glucose by causing large amounts of urine to be produced. Over time, the person loses too much fluid, resulting in dehydration.

Weight Loss: Consistent inability to metabolize and utilize glucose, fat breakdown, and increased urine output all contribute to produce significant and unintentional weight loss in people with untreated Type 1 diabetes.

Initial Management of Type 1 Diabetes

Persons with Type 1 diabetes do not produce insulin, and require insulin administration and close monitoring of blood glucose levels upon diagnosis. Unfortunately, most of those affected are usually diagnosed upon hospitalization for life threatening symptoms such as DKA. Therefore, management involves addressing the key factors which includes insulin therapy, replacing loss fluids through intravenous hydration, treating any coexisting condition such as electrolyte abnormalities, and providing counseling for the patient and available family members.

Insulin Administration: Insulin is the mainstay of therapy for persons diagnosed with Type 1 diabetes. If admitted to the hospital in the setting of DKA, the patient must be placed on insulin drip and titrated to maintain acceptable blood glucose levels. Hourly blood glucose checks are recommended in the acute phase to ensure that the patient does not become hypoglycemic (low blood glucose). Once the patient improves and is stable, frequency of glucose monitoring can be decreased and insulin administration should be scheduled to coincide with timing of blood glucose checks and meals.

Fluid Administration: Uncontrolled hyperglycemia (high blood glucose) causes dehydration due to excessive urine output as the body attempts to get rid of glucose in the blood. Therefore, fluid administration is the second most important aspect of managing these patients in the acute phase. Hydration helps to replace loss fluid, improves perfusion of vital organs, helps reduce the solute load in the blood, and correct some electrolyte abnormalities usually present in the setting of DKA.

Counseling: Counseling is so important because Type 1 diabetes is a lifelong condition that requires frequent monitoring and daily management. Most of those affected are very young at time of initial diagnosis, and may not fully understand the magnitude of the disease process. The healthcare provider has to explain as much information that is age appropriate for the affected person, and also do extensive discussion and teaching on self-monitoring and management for available family members that will participate in caring for the patient upon discharge. Patient and family counseling can booster confidence in the ability to manage the disease, and reduce the incidence of complications. Teaching must address all aspects of the disease including daily insulin administration, blood glucose checks, symptoms of DKA and other complications, as well as storage of insulin, which is a big issue in areas with unstable power supply.

Type 2 Diabetes Mellitus

Type 2 diabetes is the most common form of diabetes in the world, and the number of new cases continues to increase. In Nigeria, it affects more than 3 million people, especially persons between the ages of 40-59 years, and most are unaware of their status. Unlike Type 1 diabetes which presents with dramatic deterioration because of absolute insulin deficiency, Type 2 diabetes can remain undetected for years because the body produces enough insulin to prevent rapid decompensation and acidosis. However, they still experience symptoms of hyperglycemia (high blood glucose) such as excess thirst, excess hunger, excess urine output, and frequent urinary tract and other infections.

Type 2 diabetes is characterized by reduced sensitivity to insulin or insulin resistance. It is caused by overweight, obesity, abdominal adiposity (belly fat), and decreased physical activity. The increase in the prevalence of Type 2 diabetes in Nigeria is attributed to rapid urbanization which has promoted a more sedentary lifestyle, as well as changes in dietary patterns with increased intake of processed and sugary foods. These lifestyle changes which are mostly seen in the expanding middle and upper-class has increased the risk of diabetes. Obesity particularly in the abdominal area causes the release of large amounts of inflammatory cytokines which promote resistance to insulin and dysfunction of insulin producing cells of the pancreas, resulting in dysregulation of glucose metabolism in the body (Oluyombo et al., 2016).

Initial Management of Type 2 Diabetes

Once a person is diagnosed with this form of diabetes or found to have a degree of glucose intolerance, initial management must include recommendation of lifestyle changes to promote weight loss. This will involve increased physical activity (up to 150 minutes of aerobic activity or 75 minutes of vigorous exercise a week), and dietary modification to decrease intake of processed foods, carbohydrates and simple sugars, with a move towards a more balanced diet by increasing fruits and vegetables in appropriate portions. A combination of these factors will reduce weight gain, promote weight loss and well-being, and improve insulin sensitivity.

For those who do not achieve adequate control with lifestyle modifications, medication therapy must be initiated to improve blood glucose levels and decrease the risk of complications from hyperglycemia. There are two forms of medication therapy available; these two include oral antidiabetic agents and insulin. Initiation of medication therapy for persons with Type 2 diabetes must always begin with oral agents. The most common oral antidiabetic medication used in Nigeria is Metformin (Olamoyegun, Ibraheem, Iwuala, Audu, & Kolawole, 2015).

Metformin works by reducing glucose production in the liver, reducing glucose absorption from the digestive system, and improving insulin sensitivity. The medication is highly effective and widely available in Nigeria. However, there is need for healthcare providers and pharmacist to reinforce the importance of understanding side-effects such as hypoglycemia (low blood glucose), which might exhibit as headache, weakness, confusion, shaking, sweating, hunger, irritability, and fast heart rate. Although rare, Metformin can also cause lactic acidosis (buildup of lactic acid in the blood), particularly in persons with renal dysfunction and other health conditions. Symptoms include muscle aches and pains, numbness of arms and legs, stomach pains, nausea, vomiting, tiredness, weakness, trouble breathing, dizziness or light headedness, slow irregular heart rate etc (Lee, et al., 2017). Metformin is not recommended for people with liver problems and kidney failure, as the medication can buildup in these situations and cause severe side-effects (Lalau, 2010). Pregnant women or those breastfeeding should talk to their doctors before use because the medication is not appropriate during pregnancy, and passes through breast milk which can possibly make the breastfed baby hypoglycemic.

Failure to achieve adequate blood glucose control with oral antidiabetic agents will require initiation of insulin therapy with a goal of improving glucose control, while continuing to make lifestyle changes. The goal blood glucose level for individuals on antidiabetic medication is <110 mg/dl, but this target is hard for many to achieve.

Gestation Diabetes

Gestational diabetes is high blood glucose first diagnosed during pregnancy. It causes multiple complications including large birthweight, immature lungs and subsequent respiratory distress for the newborn baby, low blood glucose in the newborn because their bodies produced more insulin to handle the high blood glucose while they were in the womb, and premature delivery. Risk factors include age > 25 years, Body Mass Index (BMI) > 25 kg/m², previous history of gestational diabetes, family history of Type 2 diabetes, and history of poor obstetric outcomes (Bhavadharini, Uma, Saravana, & Mohan, 2016). Pregnant women should be tested for this condition between the 24-28^th week of pregnancy, and this can be done with the Oral Glucose Tolerance Test (OGTT). The OGTT measures the body’s ability to handle glucose, and involves giving a person 75 grams of glucose to drink after an 8 hour fasting period (8 hours without eating). Blood samples are collected prior to glucose administration, and at 1 and 2 hours after the glucose challenge, to assess blood glucose levels (Ogbera & Ekpebegh, 2014). According to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) Criteria, the following values indicate the presence of abnormal glucose tolerance:

Fasting blood glucose > 126 mg/dl indicates existence of diabetes before pregnancy
Fasting blood glucose > 92 mg/dl indicates gestational diabetes
1 hour after 75 grams OGTT, blood glucose > 180 mg/dl indicates gestational diabetes
2 hour after 75 grams OGTT, blood glucose > 153 mg/dl indicates gestational diabetes (Bhavadharini et al., 2016).

Gestational diabetes can resolve completely after childbirth. However, the affected woman has a higher risk of developing Type 2 diabetes, and children born to mothers with gestational diabetes have a higher risk of becoming obese and developing Type 2 diabetes later in life (Fansamade & Dagogo-Jack, 2015).

Long-term Complications of Diabetes

Long-term complications of diabetes are divided into macrovascular and microvascular complications. Microvascular complications such as Nephropathy (damage of kidneys), Retinopathy (damage of the eyes), and Peripheral Neuropathy (damage of nerves) are the most common and debilitation effects of uncontrolled diabetes over a period of time. Each of these will be discussed below.

Diabetic Nephropathy: This describes a situation where high blood glucose causes damage to the tiny blood vessels (Nephrons) that filter blood in the kidneys. If this condition is not arrested, the kidneys loses their filtering capacity over time, resulting in kidney failure. Diabetic Nephropathy is the leading cause of End-Stage Renal Disease (ESRD) in the world, and leads to dependence on dialysis to filter waste products from the blood (Sharaf El Din, Salem, & Abdulazim, 2017). Some people with diabetes may not develop ESRD, but long-term high blood glucose will eventually lead to some degree of kidney dysfunction. Early detection is key to management, and it is recommended that individuals with diabetes follow-up with a doctor to assess their urine for excretion of excess protein (albumin), because excess protein in urine (Proteinuria) is an indication of decreased filtering capacity by the kidneys (Olamoyegun et al., 2015).

Diabetic Retinopathy: This is the most common microvascular complication of diabetes, and it is characterized by damage to the small blood vessels of the eyes as a result of high blood glucose. If left undetected and untreated, it could lead to blindness (Kizor-Akaraiwe, et al, 2016). Signs and symptoms include bleeding in the eyes, cotton wool spots or floaters, blurred vision, impaired color vision, dark or empty spots in field of visor etc. Early detection is essential to reducing the risk of progression to blindness. It is important for affected individuals to follow-up with an ophthalmologist (eye doctor) for management of this condition (Olamoyegun et al, 2010).

Diabetic Peripheral Neuropathy: This is characterized by damage to the nerves of the body, particularly the hands and legs, as a result of uncontrolled high blood glucose. It is one of the late complications of diabetes. Symptoms include numbness and decreased sensitivity to pain and temperature changes, pain, tingling, and burning etc. Peripheral neuropathy predisposes the affected person to falls due to decreased balance and coordination, and the development of foot ulcers (Olamoyegun et al., 2015). Affected persons must take time to check their legs daily, wear comfortable shoes, avoid walking barefooted as decreased sensation may make it difficult to be aware of the presence of injury. It is important to be aware that peripheral neuropathy and high blood glucose decrease the ability of wounds to heal, therefore wounds in the legs may take much longer to heal and lead to severe complications such as infection, gangrene, and subsequent amputation.

Limitations to Diabetes Care in Nigeria

The biggest challenge to effective diabetes care in Nigeria is lack of financial and medical resources, which limits the ability to manage the growing population of people living with diabetes.

Lack of Financial Resources: The current Nigerian healthcare system is one in which there is no universal healthcare coverage, necessitating that individuals with health problems pay for all healthcare expenses. This places an unusual burden on people with chronic health conditions such as diabetes, which requires follow-up with healthcare providers, self-monitoring devices, and daily medication therapy. The financial burden of purchasing antidiabetic drugs can be so much that some individuals choose to skip medications to prolong drug availability, some resort to alternative medicine such as herbs in attempt to control blood glucose levels, and some stop treatment completely. This results in large numbers of people living with uncontrolled diabetes, leading to severe long-term complications from the disease process (Okoronkwo et al., 2017).

Lack of Medical Resources: Diabetes requires self-monitoring devices including Glucometer and Lancets, which are used to check blood glucose at home. Since these items are imported, the cost may be prohibitive for some individuals to purchase. Therefore, many people do not have the resources to carry out self-monitoring at home, and cannot make appropriate adjustments or know when to seek medical attention until severe complications occur. In addition, prescribed antidiabetic medications may not be available at nearby pharmacies, causing delays in treatment. For those dependent on insulin therapy, the challenge is more daunting, as they must purchase insulin frequently to maintain health, and also look for ways to preserve the potency of insulin which has to stay refrigerated in setting of unstable power supply. Diabetes is a health condition that requires management by expert medical personnel including primary care physicians, endocrinologist, ophthalmologist, podiatrist, and nurses. These all have a role to play. However, in Nigeria, most individuals with diabetes only have limited access to a general medicine doctor, who may not be able to provide the comprehensive follow-up and management required for all potential complications of the disease.

Addressing Challenges to Diabetes Care in Nigeria

Diabetes is a disease with multisystem ramifications if left uncontrolled. However, the cost of self-monitoring, management, and medical follow-up is so expensive and most people are not able to meet such demands. Therefore, it is essential that the Federal Government of Nigeria in collaboration with the Ministry of Health, continue to look for long-term solutions to improve healthcare access and delivery in Nigeria. The Nigerian Diabetic Association (NDA) must aggressively advocate for, and collaborate with healthcare providers to ensure timely diagnosis through health screening of high risk individuals, and push for the federal government to supplement some aspects of care for this vulnerable population. There is also need to raise awareness through public health campaigns, as well as doctor-to-patient counseling to ensure that the population is aware of this disease and the complications that can arise from poor management. It is imperative to emphasize the value of life-style changes including diet and exercise in preventing and controlling diabetes. Nurses can also be trained specifically to go into the community to follow-up with diabetic patients in remote areas, provide education, check blood glucose level with a Glucometer, and, and followup on the patient’s health status in general. This can help to ensure periodic blood glucose monitoring in individuals who are on medications but do not have self-monitoring devices. With expected rise in the number of people with diabetes in Nigeria, the time to act and establish protocols and systems to address this concern is now. If not, the nation will face a crisis of complications from diabetes, that will overwhelm the healthcare system.

Written by Dr. Idongesit Udoh

References

Bhavadharini, B., Uma, R., Saravanan, P., & Mohan, V. (2016). Screening and diagnosis of gestational diabetes mellitus-relevance to low and middle income countries. Clinical Diabetes and Endocrinology, 2(13). doi 10.1186/s40842-016-0031-y.

Fasanmade, O. A., & Dagogo-jack, S. (2015). Diabetes Care in Nigeria. Annals of Global Health, 81(6). doi: http//dx.doi.org/10.1016/j.aogh.2015.12.012

Jackson, I. L., Adibe, M. O., Okonta, M. J., & Ukwe, C. V. (2014). Knowledge of self-care among type 2 diabetes patients in two states of Nigeria. Pharmacy Practice, 12(3), 1-9.

Katsarou, A., Gudbjornsdottir, S., Rawshani, A., Dabelea, D., Bonifacio, E., Anderson, B. J., …Lernmark, A. (2017). Type 1 diabetes mellitus. Disease Primers, 3(17016). doi 10.1038/nrdp.2017.16.

Kizor-Akaraiwe, M. N., Ezegwu, I. R., Oguego, N., Uche, N. J., Asimadu, I. N., & Shiweobi, J. (2016). Prevalence, awareness and determinates of diabetic retinopathy in screening centre in Nigeria. Journal of Community of Health, 41, 767-771.

Lalau, J. D. (2010). Lactic acidosis induced by metformin, incidence, management and prevention. Drug safety, 33(9), 727-740.

Lee, E. Y., Hwang, S., Lee, Y., Lee, S. H., Lee, Y. M., Kang, H. P., …Lee, H. C. (2016). Association between metformin use and risk of lactic acidosis or elevated lactate concentration in type 2 diabetes. Yonsei Medical Journal, 58(2), 312-318.

Ogbera, A. O., & Ekpebegh, C. (2014). Diabetes mellitus in Nigeria: the past, present and future. World Journal of Diabetes, 5(6), 905-911.

Oguoma, V. M., Nwose, E. U., Ulasi, I. I, Akintunde, A., Chukwukelu, E. E., Bwititi, P. T., …Skinner, T. C. (2017). Cardiovascular disease risk factors in Nigerian population with impaired fasting blood glucose level and diabetes mellitus. BioMed Central Public Health, 17(36). doi 10.1186/s128889-016-3910-3.

Okonronkwo, I. L., Ekpemiro, J. N., Onwujekwe, O. E., Nwaneri, A. C., & Iheanacho, P. N. (2017). Socioeconomic inequities and payment coping mechanisms used in the treatment of type 2 diabetes mellitus in Nigeria. Nigerian Journal of Clinical Practice. doi 10.4103/1119-3077.173711.

Olamoyegun, M., Ibraheem, W., Iwuala, S., Audu, M., & Kolawole, B. (2015). Burden and pattern of micro vascular complications in type 2 diabetes in a tertiary health institution in Nigeria. African Health Sciences, 15(4), 1136-1141.

Oluyombo, R., Akinwusi, P. O., Olamoyegun, M. A., Ayodele, O. E., Fawale, M. B., Okunola, O. O., …Akinsola, A. (2016). Clustering of cardiovascular risk factors in semi-urban communities in south-western Nigeria. Cardiovascular Journal of Africa, 27(5), 322-327.

Sharaf El Din, U. A. A., Salem, M. M., & Abdulazim, D. O. 2017. Diabetic nephropathy: time to withhold development – a review. Journal of Advanced Research, 8, 363-373.

SICKLE CELL DISEASE (SCD) IN NIGERIA

Sickle Cell Disease (SCD) is a major public health concern in Nigeria. It is a complex disease that causes several complications and limits the lifespan of those affected. Approximately 25% of the population carry the sickle cell trait, and about 150,000 children are born with SCD each year. As a nation, Nigeria has the highest SCD population and trait carriers in the world. With no universal newborn screening available, most children are diagnosed once they present to the healthcare setting with suspicious symptoms that prompt the test for SCD. At this point, many of them already have complications from the disease process.

WHAT IS SICKLE CELL DISEASE?

Sickle Cell Disease (SCD) is a group of hemoglobin disorders caused by the inheritance of two alleles carrying the sickle cell mutation from both parents who have the sickle cell trait. The result is the formation of Hemoglobin S (HbS) or other forms of sickling hemoglobin including HbC, HbSC, HbSD, and HbSO. The disease is characterized by anemia and acute pain in the setting of reduced oxygen. The frequency of these two systems and the way in which they are managed is often a reflection of the level of disease control and risk of mortality for affected individuals.

Anemia is caused by the decreased lifespan of sickled red blood cells, leading to low blood counts. Acute pain on the other hand occurs when blood cells become sickled and are not able to flow freely through blood vessels. They therefore become stagnant and occlude blood supply to several organs. The disruption of blood supply to target organs prevents oxygen from being delivered to those organs, thereby causing tissue injury and organ damage, which manifest as pain in several parts of the body.

There are several systems and organs severely affected by sickle cell disease. These include:

SYSTEMS	EFFECTS OF SICKLE CELL DISEASE	MANAGEMENT
Neurologic (Brain)	Sickled cells obstruct blood flow to parts of the brain and can cause strokes especially in childhood. Approximately 10% of children with sickle cell will develop strokes, and 50% of these may have recurrent strokes. Adults with sickle cell tend to have brain hemorrhage.	Transfusions Hydroxycarbamide
Cardiovascular (Heart)	Frequent sickling of red blood cells lead to early cell death, causing anemia. Chronic anemia causes the heart to work harder just to meet the body’s demand for oxygen delivery. With time, the muscle tissue of the heart becomes enlarged, resulting in restriction in how much blood can fill the heart. This whole process causes the heart to malfunction over time. Chest pain is also another symptom experienced when there is obstruction of blood flow to heart muscles, or when the patient has severe anemia.	Transfusions Hydroxycarbamide
Pulmonary (Lungs)	People with sickle cell disease have an increased risk of developing pneumonia and restrictive lung disease which presents as difficulty breathing.	Bronchodilators Transfusions Hydroxycarbamide
Spleen	When sickle cell crisis occurs, blood becomes stagnant in the spleen and blood cells are rapidly destroyed. Parts of the spleen also become infarcted (tissue death) due to lack of oxygen caused by obstructed blood flow. These factors cause the spleen to become enlarged and non-functional over time. This condition is known as functional asplenia and predisposes affected individuals to infections.	Splenectomy (surgical removal of the spleen)
Liver	Frequent transfusions and rapid death of red blood cells results in increased bilirubin which causes jaundice. These patients also develop gallstones, and enlarged liver from sickling and occlusion of blood supply to the liver.	Cholecystectomy (removal of the gallbladder)
Kidneys	Sickle cell nephropathy starts in childhood; parts of kidney function is lost and it becomes less able to concentrate urine. The kidney at this point hyperfiltrates proteins, leading to further damage to the structures of the kidneys, and eventually end-stage renal disease.	Angiotensin Converting Enzyme Inhibitors (ACE-I) have been shown to work on the kidneys to reduce protein excretion which in turn preserves kidney function. Other options include dialysis, kidney transplant, and hydroxycarbamide to reduce the frequency of sickling
Bones and Skin	Sickle cell causes decreased blood supply to bones resulting in the death of bone tissue; a condition known as avascular necrosis. Patients also develop leg ulcers from tissue death because of decreased blood supply.	Wound care, supportive therapy, surgery if necessary
Eyes	Sickle cell causes damage to blood vessels of the eye and lead to vision loss. This condition is known as retinopathy.	May be treated with laser therapy
Penis	Sickle cell causes impotence and infertility. Male patients also experience priapism, which is a state where the penis is engorged and painful because of pooling of blood in the penis.	Surgery if necessary

MANAGEMENT OF SICKLE CELL DISEASE

Management is primarily focused on optimizing well being by preventing frequent sickle cell crisis, maintaining health, preventing infections and prolonged anemia. SCD requires management with several therapies including blood transfusions and Hydroxycarbamide

Transfusions: patients with sickle cell experience chronic anemia because of rapid destruction of red blood cells that are sickled. Therefore, transfusions are a mainstay of therapy, and the goal is to increase the oxygen carrying capacity of blood, replenish sickled and rigid blood cells, and reduce the risk of organ damage. Frequent transfusion carries its own risk including exposures to blood-borne infections such as HIV, hepatitis B and C, sensitization to antigens from donors’ blood resulting in life threatening transfusion reactions, and iron overload with deposits in tissues. Red blood cells have high iron stores, so frequent transfusions lead to a buildup of body iron stores at a rate that is faster than the body’s ability to clear it. This can be treated with chelation therapy.

Preventing Infections: most people with SCD do not have functional spleens because it is damaged in early childhood from frequent sickle cell crisis. This phenomenon is known as functional asplenia and results in increased susceptibility to infections. The spleen is an organ responsible for filtering the blood, removing some infections, storing platelets and white blood cells. The spleen therefore is a very important aspect of the immune system, and once it loses its function, the affected person becomes very susceptible to life threatening infections. People with SCD need immunization against infections such as invasive pneumococcal infections and meningitis etc. In addition, the world health organization recommends prophylactic continuous antibiotic coverage for children with sickle cell up to the age of 5. The recommended antibiotic is penicillin; other options can be used in patients with allergy to penicillin. Several studies have also shown evidence of benefits with prophylactic anti-malarial treatment as malarial infections are known to induce sickle cell crisis and increase the risk of death in children with SCD.

Hydroxycarbamide/Hydroxyurea therapy: these drugs have been a mainstay in the management of SCD for many years. They work by inducing the availability of fetal hemoglobin (HbF) which is necessary to inhibit the sickling of HbS. The therapy is well tolerated by most patients, but the cost of long-term management and availability of these drugs in low-income settings is still unclear. However, one could assume that given the healthcare system in Nigeria where patients pay out-of-pocket before receiving treatment, most may not be able to afford it, even if it was widely available.

Stem Cell Transplant/Bone Marrow Transplant: this is the only cure for SCD because it completely replaces abnormal blood forming cells with normal cells which can produce normal red blood cells. However, the therapy has several challenges including finding a matching donor, and surviving the ablative phase which is carried out to eradicate all the original blood cells prior to the infusion of new progenitor cells. The person is also high risk for bone marrow rejection and other complications which can be life threatening.

Healthy Lifestyle and Stress Management: stress management is an important aspect of disease control because physical or emotional stress can trigger crisis. Therefore, individuals with sickle cell must understand their bodies very well and their trigger points. They must hydrate well, avoid infections and promptly treat it once suspected. They must also follow-up with timely immunizations, and learn more about the disease so they can better manage themselves and be a resource to others with similar conditions. Above all, they have look to maximize well-being, happiness, and quality of life.

THE FUTURE OF SICKLE CELL DISEASE IN NIGERIA

Nigeria has the highest prevalence of SCD in the world, and there will be more cases with increasing population growth, because 1 in 4 persons carry the sickle cell trait. Therefore, it is important for the Ministry of Health to address the sickle cell epidemic by raising awareness, providing counseling, screening of newborn babies, and providing resources for management of those already affected by the disease. In addition, we must join the world in researching for therapeutic options to treat the disease and improve the quality of life for those affected.

Raising Awareness and Counseling: public health officials and healthcare providers must raise awareness about SCD, therapeutic options, complications, and the resources available to help manage the disease. Couples who plan to marry should know their status and find out if they carry the sickle cell trait, as this puts the risk of having a child with SCD at about 25% for each pregnancy when both parents are carriers. It is important to inform them of options such as invitro fertilization which can allow for the selection of normal embryos should the carrier couples decide to proceed and marry each other. Moreover, due to improved management of SCD, some individuals live into the 4^th and 5^th decade of life. With this comes a rise in the number of women with sickle cell who get pregnant and bear children. These women need special consideration because they have an increased risk of sickle cell crisis, infections, maternal, and perinatal death. Sometimes they have intrauterine growth restriction because of decreased blood flow to the babies. In normal pregnancies, the blood volume increases by about 50% to meet the needs of the growing baby, but women with sickle cell disease may not have as much increase in blood volume. Therefore, their babies are at a higher risk for intrauterine growth restriction and death. These are very high risk pregnancies and should be handled by a specialist.

Screening: universal screening of all newborn babies for SCD is available in most parts of the world. Unfortunately, despite having the largest population of individuals with sickle cell trait and SCD, Nigeria does not have universal screening. The benefits of newborn screening cannot be understated. Sickle cell symptoms do not usually appear in babies until after the third month. At that time, the fetal hemoglobin (HbF) which inhibits the sickling of HbS has diminished, so these babies begin to have symptoms of sickle cell, and tend to be diagnosed after their first crisis when they present to the hospital with swollen hands and feet. Unfortunately, if the babies were not screened prior to this incidence, some parents may opt to manage the baby at home because they are not aware that the child is experiencing a life-threatening phenomenon known as sickle cell crisis. Therefore, universal screening of all babies born in Nigeria is necessary, and database must be created to keep counts of the incidence and prevalence of SCD in Nigeria. Screening programs should be funded by the government, and will go a long way to reduce the incidence of babies who die from sickle cell because of lack of awareness and poor management.

Resources for Management of Chronic Patients: the cost of managing SCD is astronomical. Frequent transfusions and repeated hospitalizations can make the average family bankrupt in a healthcare system where funding is out-of-pocket. Therefore, the government must look to subsidize some aspects of healthcare management for this sub-population by funding newborn screening, penicillin prophylaxis for those under 5 years, and immunizations etc. These factors can go a long way to reduce morbidity and mortality in this population. There is also need for increased federal and state funding for specialty centers that manage the sickle cell population in Nigeria.

Written by Dr. Idongesit Udoh

References

Afolabi, B. B., Oladipo, O. O., Akanmu, A. S., Abudu, O. O., Sofola, O., A., & Pipkin, F. B. (2016). Volume regulatory hormones and plasma volume in pregnant women with sickle cell disorder. Journal of Renin-Angiotensin Aldosterone System. DOI 10.1177/1470320316670444.

Aneni, E. C., Hamer, D. H., & Gill, C. I. (2013). Systematic review of current and emerging strategies for reducing morbidity from malaria in sickle cell disease. Tropical Medicine and International Health, 18(3), 313-327.

Burnham-Marusich, A. R., Ezeanolue, C. O., Obiefune, M. C., Yang, W., Osuji, A., Ogidi, A. G., … Ezeanolue, E. E. (2016). Prevalence of sickle cell trait and reliability of self-reported status among expectant parents in Nigeria: implications for targeted newborn screening. Public Health Genomics, 19, 298-306.

Dosunmu, A., Akinbami, A., Uche, E., Adediran, A., John-Olabode, S. (2016). Electrocardiographic study in adult homozygous sickle cell disease patients in Lagos, Nigeria. Journal of Tropical Medicine. doi http://dx.doi.org/10.1155/2016/4214387.

Meremikwu, M. M., & Okomo, U. (2015). Sickle cell disease. Clinical Evidence, 1(2402), 1-24.

Obara, S. k., & Tam, P. Y. I. (2016). Preventing infections in sickle cell disease: the unfinished business. Pediatric Blood Cancer, 63, 781-785.

Oguntoye, O. O., Ndububa, D. A., Yusuf, M., Bolarinwa, R. A., & Ayoola, O. O. (2017). Hepatobilliary ultrasonographic abnormalities in adult patients with sickle cell anemia in steady state in ile-ife, Nigeria. Polish Journal of Radiology, 82, 1-8.

Ware, R.E., Montalembert, M., Tshilolo, L., & Abboud, M. (2017). Sickle cell disease. The Lancet. DOI http://dx.doi.org/10.1016/s0140-6736(17)30193-9.

Meningitis Outbreak In Nigeria

Statistics: The outbreak began in March 2016, approximately 15 States have been affected, almost 2000 Suspected Cases. Approximately 300 deaths so far. The states with the largest number of cases include: Kebbi, Katsina, Niger, Sokoto, Zamfara State.

Who Is In Charge of Managing The Outbreak?

Nigeria’s Centre for Disease Control is leading outbreak control in coordination with the World Health Organization (WHO), UNICEF, US Centers for Disease Control (CDC), Medecins Sans Frontieres, and Ehealth Africa
NPHCDA is leading vaccination in Zamfara state, similar efforts are being coordinated in other affected states
WHO is working to ensure the availability of vaccines.

What Are The Risk Factors?

Outbreak tends to occur in dry season because of low humidity and dusty conditions
The northern part of Nigeria seems to have a higher perdisposition because of their environment
Overcrowding and poor sanitation can contribute to outbreaks
Living in Dormitories, military bases, child facilities
Lack of Vaccination
Compromised immune system
Pregnancy increases risk of Listeria meningitis.

What Is Meningitis?

It is an Infection of the brain and spinal cord. Organisms can enter the blood stream and travel to the brain and spinal cord, or invade the meninges directly through an ear or sinus infection, skull fracture, or after surgeries in the brain or spinal area
Can be caused by bacteria, virus, or fungus
Bacterial meningitis most common in teenagers and young adults, it is very severe and can lead to death
Viral meningitis are most common in children <5 years, but often mild, can clear on its own
Fungal meningitis is rare, usually chronic, it is not contagious, and may be seen in people with immunodeficiency such as AIDS.

Bacterial Meningitis

Could be caused by multiple organisms including Streptococus Pneumonia, Haemophilus Influenzae, Listeria Monocytogenes, and most commonly Neisseria Meningitidis (N. meningitidis).
Nigeria’s current outbreak is of N. meningitidis (C serogroup), affects mostly teenagers and young adults.
Bacterial Meningitis is highly contagious, can lead to death with 24 to 48 hours if untreated.

How Bacterial Meningitis Spreads

It spreads through the respiratory system via droplets. Exposure to kissing, coughs, sneezes, shared cutlery, or sharing items that were in contact with an affected person’s saliva such as toothbrush, cigarettes etc.
Can contact meningitis by staying in an enclosed environment or room with an affected person.
Spreads very quickly in a crowded environment.

Symptoms Of Meningitis

Severe Headache that’s different from your usual
Difficulty concentrating or Confusion
Sudden high fever
Stiff neck
Sensitivity to light
Sleepiness or difficulty waking up
seizures
Poor appetite
Skin rash
Muscle and joint aches

Symptoms Of Meningitis In Infants

High fever
Irritability or Constant Crying
Poor feeding
Excessive sleepiness
Inactivity or sluggishness
Stiff neck or body
A bulge in the soft spot on the baby’s head

What To Do If You Suspect Meningitis

Prompt response and treatment can save lives and prevent complications
Avoid exposing others, wear mask and isolate yourself if possible
Go to the nearest hospital immediately
Tell the Doctor all your symptoms

Evaluation And Management Of Bacterial Meningitis

Bacterial meningitis is a medical emergency. Treatment must be initiated immediately to reduce the risk of death
Evaluate Patient for:
- Recent exposure to persons with meningitis
- Otorrhea (leaking ears) or rhinorrhea (runny nose)
- Recent travel to areas with endemic meningitis
- Recent or remote head injury
- Recent infection (especially ear infection)
- Immunocompromised conditions
- Intravenous drug use
Obtain blood cultures and Cerobrospinal (CSF) fluid through lumbar puncture if no contraindications
Initiate empiric intravenous antibiotics immediately, can use third-generation cephalosporin like cefotaxime (2grams every 4 to 6 hours) and ceftriaxone (2grams every 12 hours), or fourth-generation cephalosporin such as cefepime (2 grams every 8 hours). These drugs can consistently penetrate the cerebrospinal fluid to kill the causative organism
Chloramphenicol is preferred for N. meningitides during epidemics. Ceftriaxone can be used as an alternative if Chloramphenicol is not available or contraindicated. The World Health Organization recommends the use of chloramphenicol as the empiric antibiotic of choice in treatment of patients with N. Meningitidis in Sub-Saharan Africa. 1 or 2 injections of the long-acting formula is acceptable.
Add vancomycin (15 to 20 mg/kg every 8 to 12 hours) for empiric gram positive coverage until culture results indicate the absence of other infections
Can use dexamethasone as an adjunct to decrease brain inflammation, risk of hearing loss, and other complications
Antibiotic dosing should be adjusted for patients with poor renal function.

Complications Of Meningitis

Complications usually occurs if a person is left untreated for a long time, and includes:
Brain damage
Hearing loss
Seizures
Gait problems
Shock
Death
Memory problems and learning disabilities

Prevention of Meningitis

Vaccination of high risk populations is the best option for prevention
Vaccination against meningitis should be provided as part of the routine childhood vaccination
- Haemophilus Influenzae type B (Hib) vaccine prevents infections that cause meningitis and pneumonia
- MMR (measles-mumps-rubella) vaccine prevents meningitis caused by measles and mumps
- Pneumococcal vaccines also prevent bacterial meningitis especially in those older than 65, immunodeficient persons, or those with some chronic diseases
- Varicella (chickenpox) vaccine and shingles vaccine prevent viral meningitis
Vaccination with the Haemophilus Influenzae type B (Hib) is recommended for boarding school students or new college students
Avoid traveling to areas with meningitis outbreaks or epidemics

Written by Dr. Idongesit Udoh

References

BellaNaija (March 30, 2017). Meningtis: 1966 suspected cases reported in five states. Article obtained from http://www.bellanaija.com.

Mayo Clinic Staff. Meningitis symptoms and causes. Article obtained from http://www.mayoclinic.org/diseases-conditions/meningitis

Stephanie Busari (March 31, 2017). Meningitis outbreak in Nigeria kills nearly 300. Article obtained from http://www.cnn.com.

Tunkel, A. R., Calderwood, S. B., Thorner, A. R. (2017). Initial therapy and prognosis of bacterial meningitis in adults. Article obtained from http://www.uptodate.com

Waure, C. D., Miglietta, A., Nedovic, D., Mereu, G., & Ricciardu, W. (2016). Reduction in Neisseria meningitides infection in Italy after meningococcal C. conjugate vaccine introduction: a time trend analysis of 1994-2012 series. Human Vaccines & Immunotherapeutics, 12(2), 467-473.

World Health Organization (March 13, 2015). Meningococcal disease – Nigeria. Article obtained from http://www.who.inte/csr.

Spotlight on End-Stage Renal Disease and Therapeutic Options in Nigeria

End-Stage Renal Disease (ESRD) is a state where most of the kidney function is lost, and the individual is incapable of clearing waste products from the body, thereby leading to metabolic derangement and electrolyte imbalances. The progression from CKD to ESRD is often silent and most individuals are not aware that their renal function is deteriorating until they become symptomatic, and are diagnosed with ESRD. For most individuals in Nigeria, a diagnosis of ESRD is a death sentence because of limited availability of therapeutic options, and the exorbitant cost of that which is available. Available therapeutic options for management of ESRD includes kidney transplant, as well as peritoneal and hemodialysis. These three modalities for managing ESRD have been available in Africa and Nigeria for many years, but access to these services remains very limited because of lack of public awareness, cost, and inadequate personnel and providers in this field. Each form of renal replacement therapy (RRT) is addressed below:

Kidney Transplant: kidney transplant has been available in Nigeria for about 13 years now, but the public is largely unaware of the availability of this service in Nigeria. Many people still have negative attitudes about organ donation, therefore limiting the availability of organs for transplant candidates. Due to the lack of a formal organ donation registry, transplant candidates are dependent on the willingness of family members or friends to donate. In addition, there are very few specialist and centers capable of providing transplant services in Nigeria, so most people travel to foreign countries to obtain transplant service (Bello & Raji, 2016). For patients who are fortunate to obtain a matching organ and receive transplant, their lives are a lot more complex than the obvious, as these patients need maintenance on immunosuppressive medications to prevent organ rejection.

Peritoneal Dialysis: Peritoneal dialysis is a process whereby a dialysis fluid is infused into the peritoneum through a catheter, and the membrane acts as a filter to cleans the blood of waste products. Peritoneal dialysis is the most feasible and cheapest form of dialysis in the world. It is the cheapest because it can be taught to patients and their family members so that they can carry out dialysis treatment by themselves. The major risk factor with this form of dialysis is infection acquired in the process of infusing or exchanging the dialysis fluid, and poor sanitation in managing the equipment. However, this form of dialysis is very costly in Nigeria because the resources such as peritoneal dialysis catheters and dialysis fluid are in limited supply. The dialysis fluid in particular is imported, increasing the daily cost of management for patients that are dependent on peritoneal dialysis (Arogundade & Barsoum, 2008).

Hemodialysis: This is the most well-known form of dialysis, and can be used long-term for management of patients with ESRD or until the patient receives a kidney transplant. Hemodialysis involves filtration of the patient’s blood through a dialysis machine to cleans it of toxic waste and correct electrolyte imbalances that are often present in this patient population. Under normal circumstances, hemodialysis should occur approximately 3 times per week for optimum management of ESRD. However, Nigerians with ESRD who seek treatment with hemodialysis face several challenges including limited availability of dialysis facilities and experts, high cost of treatment which is often paid out-of-pocket directly by patients for each treatment obtained, and a high risk of exposure to blood borne infections if dialysis equipment are not properly sterilized. Therefore, most patients who require long-term dialysis do not receive optimum management because of the challenges listed above, and < 5% of patients are able to continue treatment after 3 months (Arogundade & Barsoum, 2008).

Addressing the Challenges of the ESRD Population in Nigeria

The challenges experienced by individuals with ESRD in Nigeria include high cost of treatment, limited availability of dialysis facilities, lack of a Renal Registry and logistics to promote organ donation, and risk of exposure to infections. Contributions by all stakeholders including the government, ministry of health, public health officials, healthcare providers, and non-profit organizations can help alleviate some of these challenges and provide improved care to this very vulnerable population.

Cost of Treatment: The cost of treatment is directly linked to the limited availability of facilities that are capable of providing dialysis services, and the cost of importing dialysis fluid and other supplies. Most patients in need of hemodialysis get inadequate dialysis, and the survival rate is approximately 20-70%, with most of those who survive experiencing very poor health due to malnutrition and infections (Barsoum, Khalil, & Arogundade, 2015). Therefore, the government and healthcare providers must collaborate to work on solutions by increasing funding for training of nephrologist and other specialist in the field, including dialysis nurses and technicians. The government can also give incentives to manufactures and experts that can promote the production of dialysis supplies particularly dialysis fluid in Nigeria, as this will decrease the long-term cost of management for this patient population, and promote regular dialysis which is necessary for well-being. The government must also provide a form of subsidized insurance coverage to help alleviate the financial burden on affected patients.
Availability of Dialysis Facilities: the number of facilities capable of providing dialysis and related services are very few, with most of these concentrated in large cities like Lagos. This places a significant burden on patients from rural areas and other states to travel far in order to have access to dialysis. For most of these people, the cost of traveling and lodging in a distant city in order to receive dialysis can influence their willingness to continue with treatment and the frequency in which they follow-up with regular dialysis. Therefore, future plans to improve access to renal replacement therapy should include government supported expansion of dialysis services including building new and fully staffed dialysis centers in each state in order to improve accessibility.
Renal Registry and Organ Donation: As of today, there is no formal renal registry or organ donation registry in Nigeria and most of Africa. The African Association of Nephrology (AFRAN) and African Pediatric Nephology Association (AFPNA) have an ongoing discussion about establishing a registry for kidney disease in Africa (Davids et al., 2016). A renal registry is fundamental because it would help healthcare providers and government officials ascertain the number of people affected by ESRD, and provide necessary data for research on exposures, comorbid conditions, morbidity, and mortality etc. Such data is essential to developing public health education and promoting awareness on kidney disease, developing interventions for the ESRD population, and preparing budgetary allocation for healthcare management of this group. In addition, a renal registry will increase awareness and improve logistics for kidney transplantation. Kidney transplantation is the only curative way of managing ESRD. A national registry will be beneficial in that individuals can sign up as donors, and patients could be cross-matched for donated organs and do not have to depend solely on the altruism of family members. The logistics associated with maintaining an organ donation registry is significant, but should become one of the goals for developing the healthcare system in order to meet the needs of the Nigerian people.
Infection Control: Infection control is one of, if not the most important concern for patients with ESRD who undergo dialysis. For patients with peritoneal dialysis, there is a risk of introducing bacteria and other pathogens while infusing or exchanging the dialysis fluid. These patients and their caregivers must be thoroughly educated on self-management, proper sanitation, and infection control when carrying out these procedures. For those on hemodialysis, the risk of exposure to blood borne pathogens like HIV, Hepatitis B and C, and several other infections is a huge concern. Therefore, the onus lies on healthcare providers and administrators of dialysis centers to ensure that appropriate sterilization procedures and standardized infection control measures are carried out and maintained in each dialysis facility to avoid exposing patients to life threatening infections.

Written by Dr. Idongesit Udoh

References

Arogundade, F. A., & Barsoum, R. S. (2008). CKD prevention in sub-Saharan Africa: a call for governmental, nongovernmental, and community support. American Journal of Kidney Diseases, 51(3), 515-523.

Barsoum, R. S., Khalil, S. S., & Arogundade F. A. (2015). Fifty years of dialysis in Africa: challenges and progress. American Journal of Kidney Diseases 65(3), 502-512.

Bello, B. T., & Raji, Y. R. (2016). Knowledge, attitudes and beliefs of first-degree relatives of patients with chronic kidney disease toward kidney donation in Nigeria. Saudi Journal of Kidney Diseases and Transplantation, 27(1), 118-124.

Davids, M. R., Eastwood, J. B., Selwood, N. H., Arogundade, A., Ashuntang, G., Gharbi, M. B., … Adu, D. (2016). A renal registry for Africa: first steps. Clinical Kidney Journal, 9(1), 162-167.

Kidney Disease in Nigeria

Kidney diseases are caused by many factors including injury from exposure to toxins, body fluid depletion due to blood loss or dehydration, sepsis, certain cancers, uncontrolled hypertension and diabetes etc. When these causes of dysfunction are not controlled or reversed, the person losses some of his or her kidney function permanently and can be categorized as having Chronic Kidney Disease (CKD). When most kidney function is lost, and the person cannot adequately clear toxins and waste in the body, the person is said to be in end-stage renal disease (ESRD), and at this point will require mechanical help (dialysis) to clear these toxins.

For persons with CKD who end up with ESRD in Nigeria, the process of health maintenance in this state could be very challenging as the healthcare system is ill-equipped to manage the demand for regular and adequate dialysis, and the cost could be prohibitive. Therefore, the Nigerian government in concert with healthcare leaders in the country must begin to evaluate the process of identifying at-risk and affected persons, and establish methods to ensure early intervention, and improve access to quality healthcare for this population

Identifying Risk Factors and Screening

There are several factors that predispose individuals to the development of kidney disease in Nigeria, and they include:

Volume Depletion: this is seen in cases of severe bleeding or when a person is dehydrated due to inadequate fluid intake or from losses such as prolonged diarrhea, vomiting, etc. The affected individual may be noted to be pale from blood loss, or with sunken eyes, dry mouth, low urine output etc. The goal here is to address the cause i.e control the bleeding, transfuse blood if necessary (requires hospitalization), and hydrate those with significant volume depletion (Olowu, 2015). This is the essence of the oral hydration therapy that is often taught to mothers, so that when their children have gastrointestinal illness that cause vomiting and diarrhea, they can hydrate them to prevent complications.
Glomerular Injury: glomerular injury is caused by insult to the kidneys due to exposure to toxins or infections. In children, it is often caused by streptococcal infection of the throat or skin, which triggers an immune reaction that results in the proliferation and destruction of the glomerular tissue and surrounding structures of the kidney. This process is known as Post-Streptococcal Glomerulonephritis and is the number 1 cause of kidney disease in Nigerian children. Some children with strep infection may not develop kidney disease. But for those who proceed to have this complication, it is important to identify the signs and symptoms, which includes low urine output, blood in urine, swelling of legs and body, and encourage them to seek healthcare immediately. Upon arrival to the hospital, several test should be carried out, and the most obvious result that will support this diagnosis is the presence of protein in urine (Ugwu, 2015).
Hypotension (Low Blood Pressure): hypotension can be caused by several factors including volume depletion which was discussed earlier, and sepsis which is one of the leading causes of death (Olowu, 2015). A person is said to have sepsis when the person begins to show signs of systemic response to an infection, and this will be noted with an increased heart rate, fever, low blood pressure, low urine output etc. When sepsis is not addressed immediately with resuscitation and antibiotics, it could lead to permanent damage of end organs including the kidneys and possibly death.
Chronic Uncontrolled Diabetes and Hypertension: these are the two most common causes of CKD in Nigeria. Uncontrolled diabetes is a state in which a person experiences very high blood sugar levels without adequate management with insulin or other anti-diabetic medications. Over 7% or approximately 20.8 million Nigerians are living with diabetes, and the disease burden is so significant because the cost of treatment and self-monitoring cannot be afforded by many, thereby predisposing this high-risk group to periods of significant hyperglycemia (high blood sugar) (Okoronkwo, Ekpemiro, Okwor, Okpala, & Adeyemo, 2015). Diabetes causes CKD because high blood glucose causes increased filtration through the kidneys. Over-time, the kidney tissues become damaged due to overload, resulting in increased passage of protein through the kidneys as it filters the blood, further damaging the kidneys. The end-result of this whole process is irreversible damage to the kidneys and loss of function (Adebamawo et al., 2016). Uncontrolled Hypertension on the other hand causes CKD through multiple mechanisms that promote sodium and fluid retention in the body, and neuro-hormonal responses that cause the blood vessels of the kidneys to constrict in an attempt to regulate the blood pressure. Over-time, these processes cause progressive damage to the kidneys and loss in function if not addressed (Collister, Ferguson, Komenda, & Tangri, 2016). These two conditions require long-term and consistent monitoring and management, and present a tremendous demand on the resources of the affected individual and the healthcare system. As part of an effort to address kidney disease in Nigeria, screening for, and improving the management of hypertension and diabetes should be target goals for the Federal Government, Ministry of Health, and healthcare professionals at all levels. We also need more health promotion activities to raise awareness of these risk factors, the importance of screening, treatment, and monitoring, as well as life-style alterations such as diet and exercise that can help modify the disease process and improve outcomes.

Written by Dr. Idongesit Udoh

References

Adebamowo, S. N., Adeyemo, A. A., Tekola-Ayele, F., Doumatey, A. P., Bentley, A. R., Chen, G., … Rotimi, C. N. (2016). Impact of type 2 diabetes on impaired kidney function in sub-Saharan African populations. Frontiers in Endocrinology, 7(50). doi: 10.3389/fendo.20016.00050.

Collister, D., Ferguson, T., Komenda, P., & Tangri, N. (2016). The patterns, risk factors, and prediction of progression in chronic kidney disease; a narrative review. Seminars in Nephrology, 36(4), 273-282.

Okoronkwo, I. L., Ekpemiro, J. N., Okwor, E. U., Okpala, P. U., & Adeyemo, F. O. (2015). Economic burden and catastrophic cost among people living with type2 diabetes mellitus attending a tertiary health institution in south=east zone, Nigeria. BioMed Central Research Notes, 8(527). doi:10.1186/s13104-015-1489-x.

Olowu, W. A. (2015). Acute kidney injury in children in Nigeria. Clinical Nephrology, 83(suppl 1), S70-S74.

Ugwu, G. M. (2015). Acute glomerulonephritis in children of the Niger Delta region of Nigeria. Saudi Journal of Kidney Diseases and Transplantation, 26(5), 1064-1069.

Healthcare Personnel Shortage and Solutions Continued (The Concept of Mobile Clinics, Improved Collaboration and Referral Process)

Mobile Clinics

Mobile Clinics are used in many parts of the world to deliver healthcare services to members of the population that may not have immediate access to healthcare. These are specially designed buses that are fully equipped with basic healthcare supplies, and staffed with healthcare professionals, who travel from one remote community to another and deliver care to those in need. Mobile clinics can be utilized to deliver diverse services to a target population. However, several factors need to be in place for a mobile clinic program to be successful, and these factors are listed below.

Need doctors and nurses who can function in this role
Requires government partnership and funding, because the patient population may lack the ability to pay for care delivered
Can be funded by non-profit organizations and philanthropist, and this method of funding should be encouraged
Recruitment of volunteer healthcare professionals is necessary to boost the workforce of a mobile clinic program, and decrease the cost of staffing.

Mobile clinics can be utilized for basic primary care; treatments and disease screening, immunization programs, and health campaigns. See diagram below:

The Collaboration and Referral Processes

Collaboration between healthcare providers is necessary for seamless healthcare delivery and improvement of patient outcomes. For example, if a patient with a severe cardiovascular problem goes to see a general medicine doctor who knows that the patient requires management by a cardiologist, the patient should immediately be referred to the specialist, and the generalist should carry out that consultation process to ensure that the patient is in good hands. This is sometimes lacking in Nigeria, with many providers delivering care beyond their expertise, and without seeking input from experts in particular fields of medicine, who could have influenced the quality of care rendered to the patient. In addition, patients are often left to find the experts they need to seek, and this happens after they have spent a lot of money obtaining care at a local hospital or clinic that could not address their medical problems.

To improve collaboration and referral, the following factors must be addressed:

Doctors need to collaborate with other healthcare providers in the community
Inter-institutional networking is essential to effective healthcare delivery because it allows for timely referral of patients from one institution to another based on their healthcare needs.
The referral process should be transparent, timely, and altruistic, with the sole purpose of ensuring that the patient is sent to a place that can treat the disease process effectively. Profits should never be the driving force for a referral.
The referral process should be well coordinated with detailed and necessary patient information communicated to the receiving doctor. Transportation should be facilitated to the receiving institution. See diagram below.
We need to develop an inventory that list the names, contact information, and sub-specialties for all healthcare providers within each state. This can be made available to providers and patients, making the navigation process easier when seeking consultation for complex health conditions.

Written by Dr. Idongesit Udoh

Reference

Lehmann, U., Dieleman, M., & Martineau, T. (2008). Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Services Research, 8(19). DOI 10.1186/1472-6963-8-19.