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Nigeria accounts for 39% of global malaria deaths in children under 5 years of age and the effective management of severe malaria is a health priority. The Annual Nigeria Severe Malaria Stakeholders Workshop, held on the 5–6th of July 2023 in Abuja, Nigeria brought together representatives from 36 States, the Federal Capital Territory, and other key stakeholders to address the management of severe malaria across all levels of the health service. Aims were to provide updates and review progress on severe malaria activities, the burden of disease, commodity logistics management, and pre-referral national policy implementation as well as to disseminate research findings. Two roundtable discussions were conducted to identify the challenges, barriers, and facilitators to the effective management of severe malaria in Nigeria. A key challenge was the limited awareness of updated guidelines and strategic documents among frontline health workers, leading to the misuse of non-recommended medications, like α-β-arteether. Further to this, the need to ensure appropriate treatments during pregnancy and the adoption of the WHO directive on the use of rectal artesunate were highlighted. To address these issues, innovative dissemination channels for guideline awareness were recommended and collaboration with professional organizations to enrich training materials emphasized. Other areas for improvement considered the processes involved in severe malaria management, with insufficient coordination among government agencies, inadequate referral linkages, and inadequate human resources identified as barriers. Recommendations focused on practical measures to minimize wastage of injectable artesunate, enhance data management through scaling up electronic medical records, and strengthen referral systems. The extension of severe malaria surveillance to patients older than 5 years was also proposed. To deliver these changes, actionable plans for sustained recruitment and training are needed, as well as committed advocacy at all levels to ensure timely fund disbursement and institutional support. A key overarching theme from the workshop was that a multifaceted approach was needed to address severe malaria in Nigeria, emphasizing collaborative efforts, evidence-based practices, and strategic resource allocation. With the largest malaria burden globally, the potential impact of addressing the challenges of severe malaria management in Nigeria cannot be understated and must be urgently addressed. [ABSTRACT FROM AUTHOR]

Background: Recent reports of artemisinin partial resistance from Rwanda and Uganda are worrisome and suggest a future policy change to adopt new anti-malarials. This is a case study on the evolution, adoption, and implementation of new anti-malarial treatment policies in Nigeria. The main objective is to provide perspectives to enhance the future uptake of new anti-malarials, with an emphasis on stakeholder engagement strategies. Methods: This case study is based on an analysis of policy documents and stakeholders' perspectives drawn from an empirical study conducted in Nigeria, 2019–2020. A mixed methods approach was adopted, including historical accounts, review of programme and policy documents, and 33 qualitative in-depth interviews and 6 focus group discussions. Results: Based on policy documents reviewed, the adoption of artemisinin-based combination therapy (ACT) in Nigeria was swift due to political will, funding and support from global developmental partners. However, the implementation of ACT was met with resistance from suppliers, distributors, prescribers, and end-users, attributed to market dynamics, costs and inadequate stakeholder engagement. Deployment of ACT in Nigeria witnessed increased developmental partner support, robust data generation, ACT case-management strengthening and evidence on anti-malarial use in severe malaria and antenatal care management. A framework for effective stakeholder engagement for the future adoption of new anti-malarial treatment strategies was proposed. The framework covers the pathway from generating evidence on drug efficacy, safety and uptake; to making treatment accessible and affordable to end-users. It addresses which stakeholders to engage with and the content of engagement strategies with key stakeholders at different levels of the transition process. Conclusion: Early and staged engagement of stakeholders from global bodies to community level end-users is critical to the successful adoption and uptake of new anti-malarial treatment policies. A framework for these engagements was proposed as a contribution to enhancing the uptake of future anti-malarial strategies. [ABSTRACT FROM AUTHOR]

In non-anaemic children with malaria, early-appearing anaemia (EAA) is common following artemisinin-based combination treatments (ACTs) and it may become persistent (PEAA). The factors contributing to and kinetics of resolution of the deficit in haematocrit from baseline (DIHFB) characteristic of ACTs-related PEAA were evaluated in 540 consecutive children with malaria treated with artemether-lumefantrine, artesunate-amodiaquine or dihydroartemisinin-piperaquine. Asymptomatic PEAA occurred in 62 children. In a multiple logistic regression model, a duration of illness ≤3 days before presentation, haematocrit

Background: Artemisinin-based combination therapies (ACTs) are the recommended treatment for uncomplicated Plasmodium falciparum malaria in all malaria endemic countries. Artemisinin resistance, partner drug resistance, and subsequent ACT failure are widespread in Southeast Asia. The more recent independent emergence of artemisinin resistance in Africa is alarming. In response, triple artemisinin-based combination therapies (TACTs) are being developed to mitigate the risks associated with increasing drug resistance. Since ACTs are still effective in Africa, where malaria is mainly a paediatric disease, the potential deployment of TACTs raises important ethical questions. This paper presents an analysis of stakeholders' perspectives regarding key ethical considerations to be considered in the deployment of TACTs in Africa provided they are found to be safe, well-tolerated and effective for the treatment of uncomplicated malaria. Methods: We conducted a qualitative study in Burkina Faso and Nigeria assessing stakeholders' (policy makers, suppliers and end-users) perspectives on ethical issues regarding the potential future deployment of TACTs through 68 in-depth interviews and 11 focus group discussions. Findings: Some respondents suggested that there should be evidence of local artemisinin resistance before they consider deploying TACTs, while others suggested that TACTs should be deployed to protect the efficacy of current ACTs. Respondents suggested that additional side effects of TACTs compared to ACTs should be minimal and the cost of TACTs to end-users should not be higher than the cost of current ACTs. There was some disagreement among respondents regarding whether patients should have a choice of treatment options between ACTs and TACTs or only have TACTs available, while ACTs are still effective. The study also suggests that community, public and stakeholder engagement activities are essential to support the introduction and effective uptake of TACTs. Conclusion: Addressing ethical issues regarding TACTs and engaging early with stakeholders will be important for their potential deployment in Africa. [ABSTRACT FROM AUTHOR]

Objective To explore the cost-effectiveness of parenteral artesunate for the treatment of severe malaria in children and its potential impact on hospital budgets. Methods The costs of inpatient care of children with severe malaria were assessed in four of the 11 sites included in the African Quinine Artesunate Malaria Treatment trial, conducted with over 5400 children. The drugs, laboratory tests and intravenous fluids provided to 2300 patients from admission to discharge were recorded, as was the length of inpatient stay, to calculate the cost of inpatient care. The data were matched with pooled clinical outcomes and entered into a decision model to calculate the cost per disability-adjusted life year (DALY) averted and the cost per death averted. Findings The mean cost of treating severe malaria patients was similar in the two study groups: 63.5 United States dollars (US$) (95% confidence interval, Cl: 61.7-65.2) in the quinine arm and US$ 66.5 (95% Cl: 63.7-69.2) in the artesunate arm. Children treated with artesunate had 22.5% lower mortality than those treated with quinine and the same rate of neurological sequelae: (artesunate arm: 2.3 DALYs per patient; quinine arm: 3.0 DALYs per patient). Compared with quinine as a baseline, artesunate showed an incremental cost per DALY averted and an incremental cost per death averted of US$ 3.8 and US$ 123, respectively. Conclusion Artesunate is a highly cost-effective and affordable alternative to quinine for treating children with severe malaria. The budgetary implications of adopting artesunate for routine use in hospital-based care are negligible. Objectif Etudier la rentabilite de l'artesunate parenteral dans le cadre du traitement d'enfants gravement atteints de paludisme et son impact potentiel sur les budgets hospitaliers. Methodes Les couts des soins administres aux patients hospitalises gravement atteints de paludisme ont ete evalues dans 4 des 11 sites participant a l'essai Traitement quinine/artesunate contre le paludisme en Afrique, realise sur plus de 5400 enfants. Afin de calculer le cout de l'hospitalisation, les medicaments, les essais en laboratoire et les liquides intraveineux administres a 2300 patients entre leur admission et leur sortie ont ete enregistres, ainsi que la duree de l'hospitalisation. Les donnees ont ete comparees avec les resultats cliniques regroupes et integres a un modele de decision afin de calculer le cout par annee de vie corrigee du facteur invalidite (AVCI) evite et le cout par deces evite. Resultats Le cout moyen du traitement des patients gravement atteints du paludisme s'est revele similaire dans les deux groupes experimentaux: 63,5 dollars americains (US$) (intervalle de confiance 95% IC: 61,7-65,2) pour le bras recevant la quinine et 66,5 US$ (95% IC: 63,7-69,2) pour le bras recevant l'artesunate. Les enfants traites par artesunate affichaient un taux de mortalite inferieur de 22,5% a ceux recevant de la quinine, et un taux de sequelles neurologiques identique: (bras recevant l'artesunate: 2,3 AVCI par patient; bras recevant la quinine: 3,0 AVCI par patient). En comparaison avec la quinine en tant que ligne de base, l'artesunate a demontre un cout incremental par AVCI evitee et un cout incremental par deces evite de 3,8 US$ et 123 US$, respectivement. Conclusion Dans le cadre du traitement des enfants gravement atteints de paludisme, rartesunate constitue une alternative extremement rentable et abordable par rapport a la quinine. Les implications budgetaires liees a l'adoption de l'artesunate pour une utilisation habituelle Iors des soins hospitaliers sont negligeables. Objetivo Analizar la relacion coste-eficacia del artesunato parenteral en el tratamiento de la malaria grave infantil y su posible impacto en los presupuestos hospitalarios. Metodos En cuatro de los 11 centros incluidos en el Estudio comparativo de los tratamientos de la malaria con artesunato y quinina en Africa participaron mas de 5400 ninos. Para calcular el coste de la hospitalizacion se registraron los farmacos, las pruebas clinicas y los liquidos endovenosos suministrados a 2300 pacientes, desde su ingreso hasta el alta, segun la duracion del ingreso del paciente. Los datos se compararon con los resultados clinicos agrupados e introducidos en un modelo de decision para calcular el coste por ano de vida ajustada por discapacidad (AVAD) evitada y el coste por muerte evitada. Resultados El coste medio del tratamiento de los pacientes con malaria grave fue similar en los dos grupos del estudio: 63,5 dolares estadounidenses (US$) (intervalo de confianza del 95%, IC: 61,7-65,2) en el grupo de quinina y US$ 66,5 (IC del 95%: 63,7-69,2) en el grupo de artesunato. Los ninos tratados con artesunato presentaron una mortalidad un 22,5% inferior que los tratados con quinina y la misma tasa de secuelas neurologicas: (grupo de artesunato: 2,3 AVAD por paciente; grupo de quinina: 3,0 AVAD por paciente). En comparacion con la quinina como referencia, el artesunato ha mostrado un coste incremental por AVAD evitado y un coste incremental por muerte evitada de US$ 3,8 y US$ 123, respectivamente. Conclusion El artesunato es una alternativa a la quinina muy rentable y con una excelente relacion coste-eficacia para el tratamiento de ninos con malaria grave. Las implicaciones presupuestarias de la adopcion del artesunato para su uso sistematico en la asistencia hospitalaria son insignificantes., Introduction Despite reported falling transmission in much of sub-Saharan Africa, (1-3) malaria remains a leading cause of inpatient admissions and mortality in paediatric wards. (4-6) The policy for first-line treatment [...]

Background: Although Nigeria has made some progress in malaria control, there are variations across States. We investigated the factors associated with utilisation of long-lasting insecticide-treated net (LLIN) and parasitaemia among under-five children in 13 States with high malaria burden. Method: Data from the 2015 Nigeria Malaria Indicator Survey and 2018 Demographic and Health Survey were obtained and analysed. The 2015 and 2018 data were compared to identify States with increase or reduction in parasitaemia. Analysis was done for all the 13 study States; four States with increased parasitaemia and nine States with reduction. Random-effects logit models were fitted to identify independent predictors of LLIN utilisation and parasitaemia. Results: LLIN was used by 53.4% of 2844 children, while parasitaemia prevalence was 26.4% in 2018. Grandchildren (AOR = 5.35, CI: 1.09–26.19) were more likely to use LLIN while other relatives (AOR = 0.33, CI: 0.11–0.94) were less likely compared to children of household-heads. LLIN use was more common in children whose mother opined that only weak children could die from malaria (AOR = 1.83, CI: 1.10–3.10). Children whose mothers obtained net from antenatal or immunisation clinics (AOR = 5.30, CI: 2.32–12.14) and campaigns (AOR = 1.77, CI: 1.03–3.04) were also more likely to use LLIN. In contrast, LLIN utilisation was less likely among children in female-headed households (AOR = 0.51, CI: 0.27–0.99) and those in poor-quality houses (AOR = 0.25, CI: 0.09–0.72). Children aged 24–59 months compared to 0–11 months (AOR = 1.78, CI: 1.28–2.48), those in whom fever was reported (AOR = 1.31, CI: 1.06–1.63) and children of uneducated women (AOR = 1.89, CI: 1.32–2.70) were more likely to have parasitaemia. The likelihood of parasitaemia was higher among children from poor households compared to the rich (AOR = 2.06, CI: 1.24–3.42). The odds of parasitaemia were 98% higher among rural children (AOR = 1.98, CI: 1.37–2.87). Conclusion: The key drivers of LLIN utilisation were source of net and socioeconomic characteristics. The latter was also a key factor associated with parasitaemia. These should be targeted as part of integrated malaria elimination efforts. [ABSTRACT FROM AUTHOR]

Introduction: Understanding the human immune response to Plasmodium falciparum gametocytes and its association with gametocytemia is essential for understanding the transmission of malaria as well as progressing transmission blocking vaccine candidates. Methods: In a multi-national clinical efficacy trial of artemisinin therapies (13 sites of varying transmission over South-East Asia and Africa), we measured Immunoglobulin G (IgG) responses to recombinant P. falciparum gametocyte antigens expressed on the gametocyte plasma membrane and leading transmission blocking vaccine candidates Pf s230 (Pf s230c and Pf s230D1M) and Pf s48/45 at enrolment in 1,114 participants with clinical falciparum malaria. Mixed effects linear and logistic regression were used to determine the association between gametocyte measures (gametocytemia and gametocyte density) and antibody outcomes at enrolment. Results: Microscopy detectable gametocytemia was observed in 11% (127/1,114) of participants at enrolment, and an additional 9% (95/1,114) over the follow-up period (up to day 42) (total 20% of participants [222/1,114]). IgG levels in response to Pf s230c, Pf s48/45 and Pf s230D1M varied across study sites at enrolment (p < 0.001), as did IgG seroprevalence for anti- Pf s230c and D1M IgG (p < 0.001), but not for anti- Pf s48/45 IgG (p = 0.159). In adjusted analyses, microscopy detectable gametocytemia at enrolment was associated with an increase in the odds of IgG seropositivity to the three gametocyte antigens (Pf s230c OR [95% CI], p : 1.70 [1.10, 2.62], 0.017 ; Pf s48/45: 1.45 [0.85, 2.46], 0.174 ; Pf s230D1M: 1.70 [1.03, 2.80], 0.037), as was higher gametocyte density at enrolment (per two-fold change in gametocyte density Pf s230c OR [95% CI], p : 1.09 [1.02, 1.17], 0.008 ; Pf s48/45: 1.05 [0.98, 1.13], 0.185 ; Pf s230D1M: 1.07 [0.99, 1.14], 0.071). Conclusion: Pf s230 and Pf s48/45 antibodies are naturally immunogenic targets associated with patent gametocytemia and increasing gametocyte density across multiple malaria endemic settings, including regions with emerging artemisinin-resistant P. falciparum. [ABSTRACT FROM AUTHOR]

Accurate assessment and monitoring of the Plasmodium falciparum Kelch 13 (pfk13) gene associated with artemisinin resistance is critical to understand the emergence and spread of drug-resistant parasites in malaria-endemic regions. In this study, we evaluated the genomic profile of the pfk13 gene associated with artemisinin resistance in P. falciparum in Nigerian children by targeted sequencing of the pfk13 gene. Genomic DNA was extracted from 332 dried blood (DBS) spot filter paper samples from three Nigerian States. The pfk13 gene was amplified by nested polymerase chain reaction (PCR), and amplicons were sequenced to detect known and novel polymorphisms across the gene. Consensus sequences of samples were mapped to the reference gene sequence obtained from the National Center for Biotechnology Information (NCBI). Out of the 13 single nucleotide polymorphisms (SNPs) detected in the pfk13 gene, five (F451L, N664I, V487E, V692G and Q661H) have not been reported in other endemic countries to the best of our knowledge. Three of these SNPs (V692G, N664I and Q661H) and a non-novel SNP, C469C, were consistent with late parasitological failure (LPF) in two States (Enugu and Plateau States). There was no validated mutation associated with artemisinin resistance in this study. However, a correlation of our study with in vivo and in vitro phenotypes is needed to establish the functional role of detected mutations as markers of artemisinin resistance in Nigeria. This baseline information will be essential in tracking and monitoring P. falciparum resistance to artemisinin in Nigeria. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is an underrecognized complication of severe malaria and an independent risk factor for mortality among children. Objective: To determine the incidence and factors predictive of AKI as defined by the pediatric risk, injury, failure, loss, and end-stage (pRIFLE) criteria in children with severe malaria and to assess inhospital mortality rates in malarial AKI (MAKI). Methods: This was a prospective cohort study in 170 children aged 0.5 to 14 years with confirmed Plasmodium falciparum on peripheral blood smears and clinical and/or laboratory features of severe malaria. Serum creatinine was determined using the Jaffe method and glomerular filtration rate (eGFR) was estimated using the Schwartz equation. The primary outcome was the incidence of AKI as defined by the pRIFLE criteria. Secondary outcomes included in-hospital mortality comparison between AKI and non-AKI groups, as well as factors predictive of AKI. Results: The incidence of MAKI was 61.2% and was comparable between males (66.7%) and females (70.6%). Mean eGFR was lower among children with AKI than those without [42.00 (SD 22) vs. 98.7 (SD 3.9) mL/min/1.73m2, respectively; P=0.005]. Children with MAKI were categorized as having risk (47/104; 45.2%), injury (33/104; 31.7%), or failure (24/104; 23.1%). Mortality rates in AKI and non-AKI subjects were comparable (4.8% vs. 4.6%; P=0.888). Predictors of MAKI were hemoglobinuria [adjusted OR (aOR) 3.948; 95%CI 1.138 to 8.030], deep acidotic breathing (aOR 2.991; 95%CI 3.549 to 66.898), and longer hospital stay (aOR 2.042; 95%CI 3.617 to 12.156). Children with MAKI were more likely to have a longer hospital stay by a mean of 2.5 days. Conclusion: Acute kidney injury is a common complication in children with severe malaria. Children with MAKI have a mortality rate comparable to those with severe malaria but without AKI. Hemoglobinuria, deep acidotic breathing, and longer hospital stay were predictive of MAKI. [ABSTRACT FROM AUTHOR]

Introduction: Triple artemisinin-based combination therapies (TACTs) are being developed as a response to artemisinin and partner drug resistance in the treatment of falciparum malaria in Southeast Asia. In African countries, where current artemisinin-based combination therapies (ACTs) are still effective, TACTs have the potential to benefit the larger community and future patients by mitigating the risk of drug resistance. This study explores the extent to which the antimalarial drug markets in African countries are ready for a transition to TACTs. Methods: A qualitative study was conducted in Nigeria and Burkina Faso and comprised in-depth interviews (n = 68) and focus group discussions (n = 11) with key actor groups in the innovation system of antimalarial therapies. Results: Evidence of ACT failure in African countries and explicit support for TACTs by the World Health Organization (WHO) and international funders were perceived important determinants for the market prospects of TACTs in Nigeria and Burkina Faso. At the country level, slow regulatory and implementation procedures were identified as potential barriers towards rapid TACTs deployment. Integrating TACTs in public sector distribution channels was considered relatively straightforward. More challenges were expected for integrating TACTs in private sector distribution channels, which are characterized by patient demand and profit motives. Finally, several affordability and acceptability issues were raised for which ACTs were suggested as a benchmark. Conclusion: The market prospects of TACTs in Nigeria and Burkina Faso will depend on the demonstration of the added value of TACTs over ACTs, their advocacy by the WHO, the inclusion of TACTs in financial and regulatory arrangements, and their alignment with current distribution and deployment practices. Further clinical, health-economic and feasibility studies are required to inform decision makers about the broader implications of a transition to TACTs in African counties. The recent reporting of artemisinin resistance and ACT failure in Africa might change important determinants of the market readiness for TACTs. [ABSTRACT FROM AUTHOR]

Background: The coverage of long lasting insecticidal nets (LLIN) and intermittent preventive treatment of malaria in pregnancy (IPTp) uptake for the prevention of malaria commonly vary by geography. Many sub-Saharan Africa (SSA) countries, including Nigeria are adopting the use of LLIN and IPTp to fight malaria. Albeit, the coverage of these interventions to prevent malaria across geographical divisions have been understudied in many countries. In this study, we aimed to explore the differentials in LLIN and IPTp uptake across Nigerian geopolitical zones. Methods: We analyzed data from Nigeria Multiple Indicator Cluster Survey (MICS) 2016–17. The outcome variables were IPTp and LLIN uptake among women of childbearing age (15–49 years). A total sample of 24,344 women who had given birth were examined for IPTp use and 36,176 women for LLIN use. Percentages, Chi-square test and multivariable logit models plots were used to examine the geopolitical zones differentials in IPTp and LLIN utilization. Data was analyzed at 5% level of significance. Results: The overall prevalence of IPTp was 76.0% in Nigeria. Moreover, there were differences across geopolitical zones: North Central (71.3%), North East (76.9%), North West (78.2%), South East (76.1%), South South (79.7%) and South West (72.4%) respectively. Furthermore, the prevalence of LLIN was 87.7%% in Nigeria. Also, there were differences across geopolitical zones: North Central (89.1%), North East (91.8%), North West (90.0%), South East (77.3%), South South (81.1%) and South West (69.8%) respectively. Women who have access to media use, married, educated and non-poor were more likely to uptake IPTp. On the other hand, rural dwellers and those with media use were more likely to use LLIN. Conversely, married, educated, non-poor and women aged 25–34 and 35+ were less likely to use LLIN. Conclusion: Though the utilization of IPTp and LLIN was relatively high, full coverage are yet to be achieved. There was geopolitical zones differentials in the prevalence of IPTp and LLIN in Nigeria. Promoting the utilization of IPTp and LLINs across the six geopolitical zones through intensive health education and widespread mass media campaigns will help to achieve the full scale IPTp and LLIN utilization. [ABSTRACT FROM AUTHOR]

Abstract Background Intermittent preventive treatment with sulphadoxine-pyrimethamine (IPT-SP) is currently the recommended regimen for prevention of malaria in pregnancy in endemic areas. This study sets out to evaluate the effectiveness of IPT-SP in the prevention of maternal and placental malaria in parturient mothers in Ibadan, Nigeria, where the risk of malaria is present all year round. Method During a larger study evaluating the epidemiology of congenital malaria, the effect of malaria prophylaxis was examined in 983 parturient mothers. Five hundred and ninety eight mothers (60.8%) received IPT-SP, 214 (21.8%) received pyrimethamine (PYR) and 171 (17.4%) did not take any chemoprophylactic agent (NC). Results The prevalence of maternal parasitaemia in the IPT-SP, PYR and NC groups was 10.4%, 15.9% and 17% respectively (p = 0.021). The prevalence of placental parasitaemia was 10.5% in the IPT-SP, 16.8% PYR and 17% NC groups, respectively (p = 0.015). The prevalence of maternal anaemia (haematocrit Conclusion IPT-SP is effective in preventing maternal and placental malaria as well as improving pregnancy outcomes among parturient women in Ibadan, Nigeria. The implementation of the recently adopted IPT-SP strategy should be pursued with vigour as it holds great promise for reducing the burden of malaria in pregnancy in Nigeria.

PURPOSE: Routine eye examination in early life is not the practice in most resource-limited countries. Delay in the presentation for eye problems is typical. Community health officers are often consulted by caregivers for all health problems during routine immunization and well-baby clinics in primary healthcare for children aged 0–2 years. This study evaluated the value and limitation of interview, Bruckner red reflex test, and instrument vision screener by noneye care middle-level staff of rural and urban well-baby immunization clinics, in early detection and referral for childhood eye disorders. MATERIALS AND METHODS: This was a cross-sectional study. Middle-level community health workers (CHWs) working at well-baby/ immunization clinics were trained to perform vision screening using interview of caregivers, red reflex eye examination with ophthalmoscope, and instrument vision screener (Welch Allyn SPOT™ Vision Screener) without mydriatic drugs during routine immunization of children aged 0–2 years. IRB approval was obtained. RESULTS: Over a 6-month period in 2017, the CHWs screened 5609 children. Overall, 628 (11.2%) patients were referred to the tertiary child eye care unit. Referred cases included cataract, glaucoma, congenital nasolacrimal duct obstruction, ophthalmia neonatorum, retinoblastoma, and significant refractive errors. Referral from the interview of mothers was enhanced if specific questions to elicit visual function were asked. Bruckner red reflex test was more effective than instrument vision screener in the detection of cataract and life-threatening diseases such as retinoblastoma. Instrument vision screener was preferred by parents and better at detecting amblyopic risk factors. CONCLUSION: Preschool vision screening during routine immunization by primary healthcare workers in resource-limited settings was effective. Whenever instrument vision screener does not give any recommendation during screening, consider vision- or life-threatening pathology and refer. [ABSTRACT FROM AUTHOR]

Objectives: Serum creatinine levels are often used to diagnose acute kidney injury (AKI), but may not necessarily accurately reflect changes in glomerular filtration rate (GFR). This study aimed to compare the prevalence of AKI in children with severe malaria using diagnostic criteria based on creatinine values in contrast to cystatin C. Methods: This prospective cross-sectional study was performed between June 2016 and May 2017 at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. A total of 170 children aged 0.5--14 years old with severe malaria were included. Serum cystatin C levels were determined using a particle-enhanced immunoturbidmetric assay method, while creatinine levels were measured using the Jaffe reaction. Renal function assessed using cystatin C-derived estimated GFR (eGFR) was compared to that measured using three sets of criteria based on creatinine values including the Kidney Disease: Improved Global Outcomes (KDIGO) and World Health Organization (WHO) criteria as well as an absolute creatinine cut-off value of >1.5 mg/dL. Results: Mean serum cystatin C and creatinine levels were 1.77 ± 1.37 mg/L and 1.23 ± 1.80 mg/dL, respectively (P = 0.002). According to the KDIGO, WHO and absolute creatinine criteria, the frequency of AKI was 32.4%, 7.6% and 16.5%, respectively. In contrast, the incidence of AKI based on cystatin C-derived eGFR was 51.8%. Overall, the rate of detection of AKI was significantly higher using cystatin C compared to the KDIGO, WHO and absolute creatinine criteria (P = 0.003, <0.001 and <0.001, respectively). Conclusion: Diagnostic criteria for AKI based on creatinine values may not indicate the actual burden of disease in children with severe malaria. [ABSTRACT FROM AUTHOR]

Background: In Nigeria, neonatal jaundice is commonly treated by overhead phototherapy with neonates lying supine, often with effective exposure of less than one half of the body surface. Total body exposure in phototherapy has been in use for less than 2 years in Nigeria, but is available in only five neonatal centres. Aim: To compare the effectiveness of total body exposure (TBPE) with the conventional partial exposure (COPT) for treatment of hyperbilirubinaemia. Methods: Eleven datasets from 10 neonatal units across Nigeria were retrieved. They included neonates with severe hyperbilirubinaemia treated with TBPE using the Firefly® device (MTTS Asia) as a test group. The remainder of the patients, the controls, were treated with COPT. Any requirement for exchange blood transfusion (EBT) in either group was documented. Total serum bilirubin (TSB) >213.8 μmol/L (12.5 mg/dL) was treated as severe hyperbilirubinaemia. The efficiency of the intervention was determined according to the time taken for a severe case to be downgraded to mild at ≤213.8 μmol/L. Results: A total of 486 patients were studied, 343 controls and 143 cases. Mean (SD) postnatal age was 6 days (0.7) for cases and 5 (0.9) for controls, for gestational age (GA) in completed weeks was 36 (0.5) for cases and 37 (0.7) for controls and for birthweight was 2.7 kg (0.25) for cases and 2.7 (0.22) for controls. Mean (SD) pre-intervention TSB was 299.3 (35.7) μmol/L for cases and 327.3 (13.9) for controls. Severity downgrade day was Day 2 (0.4) for cases and Day 5 (1.1) for controls. Overall relative EBT rate was 6% for cases and 55% for controls (p= 0.0001), and early preterm relative EBT rate was 0% for cases and 68% for controls (p < 0.01). Conclusion: TBPE was quicker and safer for reduction of hyperbilirubinaemia and patients rarely required EBT. TBPE is recommended for rapid reduction of serum bilirubin level s and the reduction of treatment costs, morbidity and mortality in low- and middle-income countries. Abbreviations: EBT, exchange blood transfusion; TBPE, total body exposure technique; COPT, conventional partial exposure; TSB, total serum bilirubin; SB, serum bilirubin; NNJ, neonatal jaundice; SCNU, special care neonatal unit; LMIC, low- and middle-income countries; HIC, high-income countries; LED, light-emitting diode [ABSTRACT FROM AUTHOR]

Background: The value of Cystatin C as a biomarker of Glomerular filtration rate (GFR) among African newborns is unknown, due to paucity of studies, restricting the measurement of GFR in this population of newborns to creatinine clearance despite its limitations. This study was therefore conducted to estimate GFR from serum Cystatin C in a population of Nigerian newborns and explored the relationship with anthropometrics. Methods: This was a cross-sectional, analytical study. A total of 60 healthy preterm and 30 healthy term babies were recruited at a tertiary hospital in North-central, Nigeria. Serum Cystatin C was determined using ELISA according to standard methods. Anthropometric measurements were done with standard methods. The GFR was estimated using Zappitelli's equation. Data were analyzed using SPSS Version 20, and p-value < 0.05 was considered significant. Results: Mean serum Cystatin C was 1.20 ± 0.33 (range 0.80–2.20) mg/L with comparable values in males and females (1.19 ± 0.35 vs 1.15 ± 0.31 mg/L, p = 0.481)). Mean serum Cystatin C among preterm babies were higher than term babies (1.31 ± 0.36 vs 1.01 ± 0.11 mg/L, p = < 0.001). Mean estimated GFR was 65.36 ± 16.9 ml/min/1.732 and was comparable in males and females (64.39 ± 17.95 vs 66.52 ± 15.76 ml/min/1.73 m2,p = 0.555). Estimated GFR was lower among preterm than term babies (60.10 ± 17.53 vs 75.89 ± 9.1 ml/min/1.73 m2, p = < 0.001). Serum cystatin C and estimated GFR moderately correlated with gestational age and anthropometrics (length, occipitofrontal circumference and weight). Conclusions: Serum cystatin C as a biomarker GFR among newborns is low compared with most studies done out of Africa. The serum cystatin C and estimated GFR correlated with the gestational age and anthropometric parameters. The findings relationship between the serum Cystatin C, estimated GFR and anthropometrics among the newborns suggested a need for more studies. [ABSTRACT FROM AUTHOR]

The study was based on an assessment of malaria incidence and crop productivity in Kabba/Bunu Local Government Area of Kogi State. The socio economic characteristic of households, cropping pattern, incidence of malaria and the input and output characteristics of the farming household were examined. Data were collected through the use of structured questionnaires from 72 households selected randomly in twelve villages across the local government area were monitored for eight month from May to December 2012 Households were classified based on malaria incidences as low, moderate and high respectively. Descriptive statistics and Analysis of Variance (Anova) were used for data analysis. Results show that majority of household heads (93%) were males and practiced intercropping. High malaria incidence was observed among 75% of household members during the study period. The study established a great variation in the output of crops produced among household and in the use of family labour, seed, land and fertilizer input. Crop output was higher for low malaria mobility households. It is therefore recommended that appropriate mechanism should be put in place in alleviating malaria incidence in the study area. [ABSTRACT FROM AUTHOR]

Context: Oscillometric devices are preferred method for measuring blood pressure (BP) among children. Aims: This study measured BP among school-age children using a validated oscillometric device (Omron 705 IT®) and correlated the findings with the anthropometric parameters, with a view to determine the predictors of BP. Settings and Design: This was a cross-sectional, descriptive study. A multistage stratified random sampling technique was used in the selection of pupils from primary schools in Ilorin, Nigeria. Subjects and Methods: Two serial BPs were measured used using Omron 705 IT® with appropriate cuffs using “the fourth report” guideline and standard methods were used for measurement of anthropometrics. Statistical Analysis Used: Data were analyzed using SPSS version 20. Results: A total of 1745 primary school-aged children comprising of 873 males and 872 females were recruited. Anthropometric parameters were comparable between males and females. Mean systolic and diastolic BPs were 103.8 ± 11.0 mmHg and 61.3 ± 8.4 mmHg, respectively. Mean systolic BP was lower in males compared with females (102.9 ± 10.6 mmHg vs. 104.7 ± 11.3 mmHg, respectively,P= 0.001). Mean diastolic BP in males was lower compared with females (60.7 ± 8.3 mmHg vs. 61.8 ± 8.5 mmHg, P= 0.009). Most of the anthropometric parameters correlated with the BPs. Independent predictor of BP was weight, height, and body mass index (BMI), P < 0.001. Conclusions: There was a weak correlation between the oscillometric BPs and anthropometric parameters with weight, height, and BMI been the independent predictors of BP. [ABSTRACT FROM AUTHOR]

Background: Artemisinin-based combination therapies (ACTs) have remained efficacious treatments of acute falciparum malaria in many endemic areas but there is little evaluation of factors contributing to the anaemia of acute falciparum malaria following long term adoption of ACTs as first-line antimalarials in African children.Methods: Malarious <5 year-olds randomized to artemether-lumefantrine, artesunate-amodiaquine or dihydroartemisinin-piperaquine treatments were followed up clinically for 6 weeks. Anaemia was defined as haematocrit <30%; Malaria-attributable fall in haematocrit (MAFH) as the difference between haematocrit 28-42 days post- and pre-treatment; Total MAFH (TMAFH) as the difference between days 28-42 haematocrit and the lowest haematocrit recorded in the first week post-treatment initiation; Drug-attributable fall in haematocrit (DAFH) as the difference between MAFH and TMAFH; Early appearing anaemia (EAA) as haematocrit <30% occurring within 1 week in children with normal haematocrit pre-treatment. Predictors of anaemia pre-treatment, EAA, MAFH or DAFH >4% were evaluated by stepwise multiple logistic regression models. Survival analysis and kinetics of DAFH were evaluated by Kaplan-Meier estimator and non-compartment model, respectively.Results: Pre-treatment, 355 of 959 children were anaemic. Duration of illness >2 days and parasitaemia ≤10,000 μL-1 were independent predictors of anaemia pre-treatment. EAA occurred in 301 of 604 children. Predictors of EAA were age ≤ 15 months, history of fever pre-treatment and enrolment haematocrit ≤35%. The probabilities of progression from normal haematocrit to EAA were similar for all treatments. MAFH >4% occurred in 446 of 694 children; its predictors were anaemia pre-treatment, enrolment parasitaemia ≤50,000 μL-1, parasitaemia one day post-treatment initiation and gametocytaemia. DAFH >4% occurred in 334 of 719 children; its predictors were history of fever pre-and fever 1 day post-treatment initiation, haematocrit ≥37%, and parasitaemia >100,000 μL-1. In 432 children, declines in DAFH deficits were monoexponential with overall estimated half-time of 2.2d (95% CI 1.9-2.6). Area under curve of deficits in DAFH versus time and estimated half-time were significantly higher in non-anaemic children indicating greater loss of haematocrit in these children.Conclusion: After ten years of adoption of ACTs, anaemia is common pre-and early post-treatment, falls in haematocrit attributable to a single infection is high, and DAFH >4% is common and significantly lower in anaemic compared to non-anaemic Nigerian children.Trial Registration: Pan African Clinical Trial Registry (PACTR) [ PACTR201709002064150, 1 March 2017 ]. [ABSTRACT FROM AUTHOR]

Background: Nigeria has the largest number of malaria-related deaths, accounting for a third of global malaria deaths. It is important that the country attains universal coverage of key malaria interventions, one of which is the policy of universal testing before treatment, which the country has recently adopted. However, there is a dearth of data on its implementation in formal private health facilities, where close to a third of the population seek health care. This study identified the level of use of malaria rapid diagnostic testing (RDT), compliance with test results and associated challenges in the formal private health facilities in Nigeria. Methods: A cross-sectional study that involved a multi-stage, random sampling of 240 formal private health facilities from the country's six geo-political zones was conducted from July to August 2014. Data were collected using health facility records, healthcare workers' interviews and an exit survey of febrile patients seen at the facilities, in order to determine fever prevalence, level of testing of febrile patience, compliance with test results, and health workers' perceptions to RDT use. Results: Data from the 201 health facilities analysed indicated a fever prevalence of 38.5 % (112,521/292,430). Of the 2077 exit interviews for febrile patients, malaria testing was ordered in 73.8 % (95 % CI 71.7-75.7 %). Among the 1270 tested, 61.8 % (719/1270) were tested with microscopy and 38.2 % (445/1270) with RDT. Compliance to malaria test result [administering arteminisin-based combination therapy (ACT) to positive patients and withholding ACT from negative patients] was 80.9 % (95 % CI 78.7-83 %). Compliance was not influenced by the age of patients or type of malaria test. The health facilities have various cadres of the health workers knowledgeable on RDT with 70 % knowing the meaning, while 84.5 % knew what it assesses. However, there was clearly a preference for microscopy as only 20 % reported performing only RDT. Conclusion: In formal private health facilities in Nigeria there is a high rate of malaria testing for febrile patients, high level of compliance with test results but relatively low level of RDT utilization. This calls for improved engagement of the formal private health sector with a view to achieving universal coverage targets on malaria testing. [ABSTRACT FROM AUTHOR]

Background. The stability of the human immunodeficiency virus type 1 (HIV-1) reservoir and the contribution of cellular proliferation to the maintenance of the reservoir during treatment are uncertain. Therefore, we conducted a longitudinal analysis of HIV-1 in T-cell subsets in different tissue compartments from subjects receiving effective antiretroviral therapy (ART). Methods. Using single-proviral sequencing, we isolated intracellular HIV-1 genomes derived from defined subsets of CD4+ T cells from peripheral blood, gut-associated lymphoid tissue and lymph node tissue specimens from 8 subjects with virologic suppression during long-term ART at 2 time points (time points 1 and 2) separated by 7-9 months. Results. DNA integrant frequencies were stable over time (<4-fold difference) and highest in memory T cells. Phylogenetic analyses showed that subjects treated during chronic infection contained viral populations with up to 73% identical sequence expansions, only 3 of which were observed in specimens obtained before therapy. At time points 1 and 2, such clonally expanded populations were found predominantly in effector memory T cells from peripheral blood and lymph node tissue specimens. Conclusions. Memory T cells maintained a relatively constant HIV-1 DNA integrant pool that was genetically stable during long-term effective ART. These integrants appear to be maintained by cellular proliferation and longevity of infected cells, rather than by ongoing viral replication. [ABSTRACT FROM AUTHOR]

Background. Data from the largest randomized, controlled trial for the treatment of children hospitalized with severe malaria were used to identify such predictors of a poor outcome from severe malaria Methods. African children (<15 years) with severe malaria participated in a randomized comparison of parenteral artesunate and parenteral quinine in 9 African countries. Detailed clinical assessment was performed on admission. Parasite densities were assessed in a reference laboratory. Predictors of death were examined using a multivariate logistic regression model. Results. Twenty indicators of disease severity were assessed, out of which 5 (base deficit, impaired consciousness, convulsions, elevated blood urea, and underlying chronic illness) were associated independently with death. Tachypnea, respiratory distress, deep breathing, shock, prostration, low pH, hyperparasitemia, severe anemia, and jaundice were statistically significant indicators of death in the univariate analysis but not in the multivariate model. Age, glucose levels, axillary temperature, parasite density, heart rate, blood pressure, and blackwater fever were not related to death in univariate models Conclusions. Acidosis, cerebral involvement, renal impairment, and chronic illness are key independent predictors for a poor outcome in African children with severe malaria. Mortality is markedly increased in cerebral malaria combined with acidosis. [ABSTRACT FROM AUTHOR]

Glucose-6-phosphate (G6P) is an enzyme in the hexose monophosphate shunt required for the production of reducing equivalents needed to mop up free radicals. thereby keeping hemoglobin in its free state. Deficiency of the enzyme can cause severe neonatal jaundice. The aim of this study was to compare G6PD levels in pre-term and term babies, and evaluate the extent to which G6PD deficiency determines the severity of jaundice in various gestational age groups. Samples of cord blood collected from consecutively delivered babies in the University of Ilorin Teaching Hospital, Nigeria, were assayed for G6PD levels, and the babies were observed for jaundice during the first week of life. Those who developed jaundice had serial serum bilirubin measured. Nine hundred and thirty-three babies had G6PD assayed, with 348 being G6PD deficient, giving a hospital based prevalence of 37.3%. Of the 644 who were followed up, 143 (22.2%) were pre-term and 501(77.8%) were term babies. Babies with gestational age (GA) 27-29 weeks had the highest G6PD levels. However, there was no significant variation among the different gestational age groups (F=0.64, P=0.64). Jaundice occurred more in pre-term compared to term babies with a relative risk of 2.41 (X2=60.95, P=0.00001). Occurrence of jaundice in pre-term babies was irrespective of G6PD status (X2=0.2, P=0.66, RR=1.09, CI=0.832=- 0.874). Pre-term babies are more likely to have higher G6PD levels, but occurrence of jaundice in pre-term babies is irrespective of G6PD status. More severe jaundice (especially for gestational age) occurring in pre-term babies requires critical care. [ABSTRACT FROM AUTHOR]

Successful control of malaria depends upon the detailed knowledge of its epidemiology, including the knowledge of environmental, behavioral, socio-economic and socio-demographic factors that influence its prevalence, and on the knowledge and use of preventive measures. We carried out a cross-sectional study to assess the risk factors for malaria in children presenting with fever in rural Gambia. Three hundred and seventy-six children aged 5 months to 10 years presenting to Farafenni health centre, the Gambia with fever or history of fever were enrolled. The socio-demographic characteristics, clinical findings, and knowledge and use of preventive measures in malaria were documented. Finger-prick blood sampling for malaria was obtained and two sets of smears (thick and thin) were prepared and stained with Giemsa stain. One hundred and eighty two children (48.4% had malaria. The significant risk factors associated with malaria were non-use of insecticide treated bed nets [χ ^{2} = 8.82, P =0.01, (95% confidence interval 0.10-0.67)] and age [χ ^{2} = 9.18, P=0.004, (95% confidence interval 0.31-0.78)]. There were no significant associations identified between the development of malaria and parental education, occupation, knowledge of the cause of malaria, type of roof or wall in the home, or whether the parents reared livestock. [ABSTRACT FROM AUTHOR]