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Survivors of human-initiated disaster are at high risk for mental disorder, most notably post-traumatic stress disorder (PTSD). Studies of PTSD have tended to focus on soldiers returning home after combat or on refugees living in resettlement countries under conditions of relative safety. However, most survivors of human-initiated disasters continue to live in or near the places where they initially experienced trauma. Insufficient attention has been paid to social disorganization in situations of continuing unrest and to its role in creating or stabilizing the symptoms of PTSD. The current study took place in the Niger Delta region of Nigeria, the scene of long-standing violence and human rights abuse that reached its apogee in 1995. The investigation, which took place in 2002, focused on two villages, one that was heavily exposed to the conflict (A, the affected village), the other relatively spared (NA, not affected). Probability samples of 45 adult residents from A and 55 from NA were interviewed with a schedule that contained the PTSD module from the WHO Diagnostic Interview Schedule. The schedule also contained a measure of exposure to the violence and abuses during the height of the conflict, as well as measures of structural and social capital that are components of community resilience. These included economic security, a sense of moral order, a sense of safety and perceived social support. The six month period prevalence of PTSD was 60 percent in A, and 14.5 percent in NA. Degree of exposure to stress as well as compromised sense of moral order, not feeling safe, and perceived lack of social support were independent predictors of PTSD. In places like the Niger Delta, where people do not physically escape from past trauma, sociocultural disintegration may interfere with communal functioning, thereby eroding community capacity to promote self-healing. [ABSTRACT FROM AUTHOR]

Background: Lack of or use of suboptimal cold chain equipment (CCE) is a major barrier to optimal immunization coverage and equity. Gavi established the CCE optimization platform (CCEOP) in 2015 to help eligible countries modernize their cold chain systems. However, there are limited data on CCE deployment at country level. We present lessons learnt from deploying CCE from the Gavi CCEOP in Cameroon., Methods: This cross-sectional study collected data on the number of days items of CCE spent at each point on their trajectory from the entry port to 62 randomly selected health facilities in Cameroon., Results: Once equipment arrived at the entry port, it took 10 d for customs clearance, 2 d from customs clearance to warehousing and 257 d (>9 mo) from the warehouse to facilities. Upon arrival at the facilities, it took a median of 53 (range 0-395) d from installation to final commissioning: most of the days (median=210) were spent between installation and final commissioning. The major causes of delays included insufficient coordination and communication across all levels, poor documentation and final commissioning., Conclusion: Early engagement on customs clearance, strengthening coordination and communication, ensuring proper documentation, as well as eliminating final commissioning, could significantly improve implementation of the program., (© The Author(s) 2024. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Nigeria adapted the WHO package of care for Advanced HIV Disease (AHD) in 2020. The package includes CD4 + cell count testing to identify People Living with HIV (PLHIV) with AHD, screening and treatment of opportunistic infections, rapid antiretrovirals (ART) initiation, and intensive adherence follow-up. The national program adopted a phased approach in the rollout of the AHD package of care to learn lessons from a few representative health facilities before scaling up across the country. This study describes the process and lessons learned from the first phase of implementation., Methods: This was a prospective observational study, and participants were enrolled between February and September 2021. Healthcare-worker (HCW) capacity was built to implement the AHD package of care. The study population included newly diagnosed PLHIV ≥ 10 years presenting to care in 28 selected facilities across 4 states in Nigeria. Eligible participants received CD4 + cell testing at baseline. Those with CD4 + cell count < 200 cells/mm 3 were subjected to a blood cryptococcal antigen (CrAg) test and urine TB lateral flow lipoarabinomannan (LF-LAM). Those with positive CrAg tests had a cerebrospinal fluid (CSF) test to confirm cryptococcal meningitis. Those negative for both blood CrAg and TB LF-LAM were rapidly initiated on ART and underwent intensive follow-up. Participants were followed up for 12 months., Results: A total of 6,781 patients were enrolled; 71% (4,812) received CD4 + cell count test, of which 41% (1,969 of 4812) had a CD4 + count < 200 cells/mm 3 . Approximately 81% (1,492 of 1,850) of those with CD4 + count < 200 cells/mm 3 had TB LF-LAM test results documented; 25% were positive, of which 47% started TB treatment. Blood CrAg screening coverage among those with CD4 + count < 200 cells/mm 3 was 88% (1,634 of 1,850), of which 5% (85 of 1,634) were positive. Cotrimoxazole preventive therapy was initiated for 65% (1,198 of 1,850) of the participants with CD4 + count < 200 cells/mm 3 , and 70% (966 of 1,375) of AHD patients with a negative TB LF-LAM and blood CrAg results were initiated on ART on the day of enrolment. Approximately 91% (421 of 461) of those who received viral load results at month 12 post-enrollment were virally suppressed. The retention rate and the Kaplan Meier survival probability estimate at month 12 were 65% (1,204 of 1,850) and 0.93 (CI, 0.91-0.94), respectively, for the enrolled participants., Conclusion: Implementation of the AHD package of care in Nigeria has improved the diagnosis of TB and CM, and will potentially enhance the quality of care for PLHIV if sustained. Findings from this implementation were used to guide national scale-up., Competing Interests: Declarations. Ethics approval and consent to participate: Approval for the study was secured from the National Health Research Ethics Committee of Nigeria with approval number NHREC/01/01/2007-27/01/2021 as part of the operations research for the first phase of implementation of the AHD package of care in Nigeria. Participants were not subjected to any additional risk beyond that involved in receiving HIV treatment in Nigeria. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Objectives: Vaccine stockouts at the national level has been recognized as a critical challenge in ensuring sustained and equitable immunization coverage. These stockouts often arise from inherent issues within countries, including delays in government funding, suboptimal forecasting and stock management practices, and inefficiencies in the procurement process amongst others. Understanding the complexities and barriers within vaccine procurement and financing systems is crucial for developing effective strategies to enhance vaccine availability and strengthen immunization programs. This is particularly relevant in the context of reaching zero dose children and transitioning from Gavi. This study aimed to comprehensively assess the vaccine procurement and financing landscape in Cameroon from 2015 to 2020., Study Design: This was a descriptive cross-sectional study., Methods: Employing a mixed-methods approach, we conducted a desk review of pertinent documents and engaged in in-depth interviews with key stakeholders involved in the procurement and funding mobilization processes. Through data collection and analysis using Microsoft Excel 365 and Dedoose software, we delineated the intricacies of the procurement process and pinpointed specific barriers that have contributed to vaccine stockouts., Results: The mapping of vaccine procurement processes revealed complexity, protracted timelines, and the involvement of multiple stakeholders. The Expanded Program on Immunization (EPI) faced a USD 4 million funding deficit for vaccine procurement between 2016 and 2019. Consequently, the program experienced delays in acquiring 20 million vaccine doses, leading to 41 months of stockout for at least one antigen. Major bottlenecks identified by key stakeholders in vaccine procurement and financing encompassed delayed fund mobilization, inefficient and lengthy processes for fund mobilization and disbursement, poor data utilization, and discrepancies between forecasted, allocated, and mobilized funds., Conclusion: The findings of this research hold significant implications for many EPIs. By elucidating procurement and financing challenges, we can formulate evidence-based recommendations aimed at optimizing resource allocation, streamlining procurement processes, and bolstering vaccine availability. These insights are essential for fostering collaboration between government agencies, technical partners, and financial partners to achieve sustainable vaccine access in Cameroon. Establishing a joint procurement working group could streamline processes, potentially reducing stockouts and improving vaccine coverage., (Copyright © 2024. Published by Elsevier Ltd.)

Background and Objective: The burden of maternal mortality attributable to postpartum hemorrhage (PPH) remains high in Nigeria. Currently, oxytocin, and misoprostol, which are largely of suboptimal quality, are used for PPH prevention and treatment. Heat-stable carbetocin (HSC) is a viable uterotonic option for PPH prevention in a setting like Nigeria where compromised supply and cold chain systems result in the preponderance of poor-quality oxytocin and suboptimal PPH management. It is crucial to understand how healthcare providers (HCPs) accept and use HSC for PPH prevention, and what factors encourage correct uterotonic usage in health facilities, given PPH's ongoing public health challenge. This study aims to elucidate the current prophylactic use of HSC, oxytocin, and misoprostol in secondary and tertiary public health facilities while assessing HSC acceptability to clinicians and establishing factors that enable the appropriate use of uterotonics in health facilities., Methods: Descriptive analysis conducted on quantitative data from patient chart reviews, HCP interviews and assessment, and facility assessment using Stata 15 and Microsoft Excel are presented as counts and percentages, while qualitative data from key informant interviews and in-depth interviews are coded and analyzed using NVivo. The findings from 18 publicly owned secondary and tertiary healthcare facilities across Kano, Lagos, and Niger states in Nigeria were interpreted according to thematic areas. Health facilities selection criteria were high volume of deliveries (≥30 deliveries per month), accessible location, availability of trained HCPs (specifically doctors, nurses, and midwives), and willingness to participate in the study., Results: HSC was administered prophylactically in 10,284 (56%) of 18,364 deliveries, with a total of 148 (0.8%) women developing PPH. Approximately 76% of HCPs preferred HSC for PPH prevention compared to other available uterotonics, with clinical guidance from senior HCPs (76%), in-service training (76%), mentoring (84%), and supportive supervision (75%) contributing significantly to the choice and practice of uterotonics use by HCPs., Conclusion and Global Health Implications: HSC, a thermostable analog of oxytocin, holds the potential to prevent PPH without the added cost of administering additional uterotonics and interventions. The introduction of HSC requires concerted procurement and capacity-building efforts to create an enabling environment for scale-up. HSC is non-inferior to oxytocin in preventing PPH, has few side effects compared to misoprostol or oxytocin-misoprostol combination, and more cost-effective when compared with the other three uterotonics. Although the geographical scope of our study is only three states in Nigeria, the preponderance of suboptimal uterotonics across the country makes our findings applicable to the whole country and other low- and middle-income countries with similar challenges., Competing Interests: The authors have no conflicts of interest., (© 2024 The Authors. Published by Global Health and Education Projects, Inc., USA.)

High vaccine wastage can serve as a critical barrier to achieving the gains of vaccination, especially in a country like Nigeria, where data on vaccine wastage are sparsely available. We determined the country-wide vaccine wastage rates and their determinants through a mixed-methods study conducted across 576 health facilities (primary and secondary) in 24 states in Nigeria. We collected facility-based immunization records from June 2018 to May 2019, in addition to healthcare workers' interviews and observations of fixed and outreach sessions. The results show that open-vial wastage ranged from 21.2% (95% CI: 20.2%, 22.2%) for the pentavalent vaccine to 72.6% (95% CI: 71.5%, 73.6%) for BCG. Open-vial wastage rates for BCG, measles, and yellow fever vaccines were higher during outreach sessions, with rates of 76.2%, 64.3%, and 65.2%, respectively. For the outreach and fixed sessions, PCV and Penta had the least wastages of 22.0% for fixed sessions and 20.4% for outreach sessions. This study identified vaccine presentation (liquid vs. lyophilized vaccines), vial size (4 dose vs. 5 dose vs. 10 dose vs. 20 dose), RI service delivery strategies (fixed vs. outreach sessions), number of children vaccinated, and human resources (healthcare workers position/cadre) as key determinants of vaccine wastages in Nigeria.

Malaria remains a major health priority in Nigeria. Among children with fever who seek care, less than a quarter gets tested for malaria, leading to inappropriate use of the recommended treatment for malaria; Artemisinin-based Combination Therapy (ACT). Here we test an innovative strategy to target ACT subsidies to clients seeking care in Nigeria's private retail health sector who have a confirmed malaria diagnosis. We supported point-of-care malaria testing (mRDTs) in 48 Private Medicine Retailers (PMRs) in the city of Lagos, Nigeria and randomized them to two study arms; a control arm offering subsidized mRDT testing for USD $0.66, and an intervention arm where, in addition to access to subsidized testing as in the control arm, clients who received a positive mRDT at the PMR were eligible for a free (fully subsidized) first-line ACT and PMRs received USD $0.2 for every mRDT performed. Our primary outcome was the proportion of ACTs dispensed to individuals with a positive diagnostic test. Secondary outcomes included proportion of clients who were tested at the PMR and adherence to diagnostic test results. Overall, 23% of clients chose to test at the PMR. Test results seemed to inform treatment decisions and resulted in enhanced targeting of ACTs to confirmed malaria cases with only 26% of test-negative clients purchasing an ACT compared to 58% of untested clients. However, the intervention did not offer further improvements, compared to the control arm, in testing rates or dispensing of ACTs to test-positive clients. We found that ACT subsidies were not passed on to clients testing positive in the intervention arm. We conclude that mRDTs could reduce ACT overconsumption in Nigeria's private retail health sector, but PMR-oriented incentive structures are difficult to implement and may need to be complemented with interventions targeting clients of PMRs to increase test uptake and adherence. Trials registration: Clinical Trials Registration Number: NCT04428307. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816435/ Correction: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9476591/., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Visser et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Medical oxygen is essential for managing hypoxaemia, which has a multifactorial origin, including acute and chronic lung diseases such as pneumonia, asthma, and severe malaria. The coronavirus disease 2019 (COVID-19) revealed substantial gaps in the availability and accessibility of safe medical oxygen, especially in low- and middle-income countries (LMICs). This study aimed to assess the availability and sources, as well as the barriers to the availability of functional medical oxygen in hospitals in Cameroon., Methods: This was a nationwide cross-sectional descriptive study conducted from 26 March to 1 June 2021. Using a convenient sampling technique, we sampled accredited public and private COVID-19 treatment centres in all ten regions in Cameroon. Representatives from the selected hospitals were provided with a pre-designed questionnaire assessing the availability, type, and state of medical oxygen in their facilities. All analyses were performed using R., Results: In total, 114 hospitals were included in this study, with functional medical oxygen available in 65% (74/114) of the hospitals. About 85% (23/27) of the reference hospitals and only 59% (51/87) of the district hospitals had available functional medical oxygen. Compared to district hospitals, reference hospitals were more likely to have central oxygen units (reference vs. district: 10 vs. 0%), oxygen cylinders (74 vs. 42%), and oxygen concentrators (79 vs. 51%). The most common barriers to the availability of medical oxygen were inadequate oxygen supply to meet needs (district vs. reference hospitals: 55 vs. 30%), long delays in oxygen bottle refills (51 vs. 49%), and long distances from oxygen suppliers (57 vs. 49%)., Conclusions: The availability of medical oxygen in hospitals in Cameroon is suboptimal and more limited in districts compared to reference hospitals. The cost of medical oxygen, delays related to refills and supplies, and long distances from medical sources were the most common barriers to availability in Cameroon., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

Background: An estimated 50% of suspected malaria cases in sub-Saharan Africa first seek care in the private sector, especially in private medicine retail outlets. Quality of care in these outlets is generally unknown but considered poor with many patients not receiving a confirmatory diagnosis or the recommended first-line artemisinin-based combination therapy (ACT). In 2010, a subsidy pilot scheme, the Affordable Medicines Facility malaria, was introduced to crowd out the use of monotherapies in favour of WHO-pre-qualified artemisinin-based combinations (WHO-PQ-ACTs) in the private health sector. The scheme improved the availability, market share, and cost of WHO-PQ-ACTs in countries like Nigeria and Uganda, but in 2018, the subsidies were halted in Nigeria and significantly reduced in Uganda. This paper presents findings from six retail audit surveys conducted from 2014 to 2021 in Nigeria and Uganda to assess whether the impact of subsidies on the price, availability, and market share of artemisinin-based combinations has been sustained after the subsidies were reduced or discontinued., Methods: Six independent retail audits were conducted in private medicine retail outlets, including pharmacies, drug shops, and clinics in Nigeria (2016, 2018, 2021), and Uganda (2014, 2019, 2020) to assess the availability, price, and market share of anti-malarials, including WHO-PQ-ACTs and non-WHO-PQ-ACTs, and malaria rapid diagnostic tests (RDTs)., Results: Between 2016 and 2021, there was a 57% decrease in WHO-PQ-ACT availability in Nigeria and a 9% decrease in Uganda. During the same period, non-WHO-PQ-ACT availability increased in Nigeria by 41% and by 34% in Uganda. The price of WHO-PQ-ACTs increased by 42% in Nigeria to $0.68 and increased in Uganda by 24% to $0.95. The price of non-WHO-PQ-ACTs decreased in Nigeria by 26% to $1.08 and decreased in Uganda by 64% to $1.23. There was a 76% decrease in the market share of WHO-PQ-ACTs in Nigeria and a 17% decrease in Uganda. Malaria RDT availability remained low throughout., Conclusion: With the reduction or termination of subsidies for WHO-PQ-ACTs in Uganda and Nigeria, retail prices have increased, and retail prices of non-WHO-PQ-ACTs decreased, likely contributing to a shift of higher availability and increased use of non-WHO-PQ-ACTs., (© 2024. The Author(s).)

Background: Despite growing efforts to improve access to vaccination, millions of children, especially in developing countries, have not received a single dose of diphtheria, tetanus, and pertussis (DTP) vaccine. Consequently, they are often called zero-dose children (ZDC). With limited health resources, prioritising communities for rapid and mass zero-dose catch-up vaccination in missed communities to avert epidemic outbreaks is complicated by unreliable denominators used to compute vaccination coverages. Incorporating other indicators of access and utilisation of vaccination services can help with identifying and ranking missed communities based on the likelihood of finding ZDC. We described the process of generating a scoring method to rank health areas in Cameroon based on their likelihood of containing ZDC., Methods: We used geospatial analysis to compute and aggregate health area characteristics, including hard-to-reach (HTR) areas (defined as areas of settlement above a one- (for urban areas) or 15-kilometre radius (for rural areas) beyond a vaccinating health facility), amount of area covered by slums and new area settlement, and percentage of children unvaccinated for DTP-1. We attributed a weight based on the ability to limit accessibility or utilisation of vaccination services to each characteristic and computed the score as a weighted average of health area characteristics. The health area score ranged from 0 to 1, with higher scores representing a higher likelihood of containing ZDC. We stratified the analysis by rural and urban health areas., Results: We observed substantial district and regional variations in health area scores, with hotspots health areas (administrative level 4) observed in the Far North (0.83), North (0.81), Adamawa (0.80), East (0.75), and South West (0.67) regions. The Adamawa region had the highest percentage of health areas with the highest score (78%), followed by the East (50%), West (48%), and North (46%) regions. For most regions (Far North, South, South West, Littoral, West, and North West), DTP-1 contributed the most to the score. However, HTR settlement areas within a health area contributed substantially to the overall score in the East, North, and Adamawa regions., Conclusions: We found substantial variations in health area scores with hotspots in the Far North, North, Adamawa, East, and South West regions. Although DTP-1 could be used as an indicator to identify health areas with ZDC for most communities, HTR settlement area was a valuable indicator in ranking priority health areas in the East, North, and Adamawa regions, further emphasising the need to consider other indicators before prioritisation., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2023 by the Journal of Global Health. All rights reserved.)

Background: Immunization is regarded as one of the most cost-effective public health interventions in global health. However, its cost-effectiveness depends greatly on the knowledge and skills of vaccinators. With the growing complexity of immunization programs, the need for a well-trained vaccination workforce cannot be overemphasized. In this study, we assessed the knowledge, attitudes, and practices among vaccination staff in Cameroon., Methods: Through a descriptive cross-sectional design, we used structured questionnaires and observation guides to collect data from vaccination staff in health facilities that were selected by a multistage sampling method. Data were analyzed using STATA 13 software., Results: Overall, we collected data from Expanded Program on Immunization focal staff in 265 health facilities across 68 health districts. Over half (53%) of the surveyed facilities were found in rural areas. Nearly two-thirds of health facilities had immunization focal staff with knowledge gaps for each of the four basic immunization indicators assessed. In other words, only 37% of staff knew how to estimate coverages, 36% knew how to inteprete the EPI monitoring curve, 35% knew how to prepare vaccine orders, and 37% knew how to estimate vaccine wastage. In terms of practices, staff waited for more than ten children to be present before opening a 20-dose vaccine vial in 63% of health facilities, and more than five children to be present before opening a 10-dose vaccine vial in 80% of surveyed facilities. Provision of vaccine-specific information (informing caregiver about vaccine received, explanation of benefits and potential side effects) during immunization sessions was suboptimal for the most part., Conclusion: This study suggests marked deficits in immunization knowledge among vaccination staff and exposes common attitudes and practices that could contribute to missed opportunities for vaccination and hinder vaccination coverage and equity in Cameroon. Our findings highlight the urgent need to invest in comprehensive capacity building of vaccination staff in Cameroon, especially now that the immunization program is becoming increasingly complex., (© 2023. The Author(s).)

Background: One crucial obstacle to attaining universal immunization coverage in Sub-Saharan Africa is the paucity of timely and high-quality data. This challenge, in part, stems from the fact that many frontline immunization staff in this part of the world are commonly overburdened with multiple data-related responsibilities that often compete with their clinical tasks, which in turn could affect their data collection practices. This study assessed the data management practices of immunization staff and unveiled potential barriers impacting immunization data quality in Cameroon., Methods: A descriptive cross-sectional study was conducted, involving health districts and health facilities in all 10 regions in Cameroon selected by a multi-stage sampling scheme. Structured questionnaires and observation checklists were used to collect data from Expanded Program of Immunization (EPI) staff, and data were analyzed using STATA VERSION 13.0 (StataCorp LP. 2015. College Station, TX)., Results: A total of 265 facilities in 68 health districts were assessed. There was limited availability of some data recording tools like vaccination cards (43%), maintenance registers (8%), and stock cards (57%) in most health facilities. Core data collection tools were incompletely filled in a significant proportion of facilities (37% for registers and 81% for tally sheets). Almost every health facility (89%) did not adhere to the recommendation of filling tally sheets during vaccination; the filling was instead done either before (51% of facilities) or after (25% of facilities) vaccinating several children. Moreso, about 8% of facilities did not collect data on vaccine administration. About a third of facilities did not collect data on stock levels (35%), vaccine storage temperatures (21%), and vaccine wastage (39%)., Conclusion: Our findings unveil important gaps in data collection practices at the facility level that could adversely affect Cameroon's immunization data quality. It highlights the urgent need for systematic capacity building of frontline immunization staff on data management capacity, standardizing data management processes, and building systems that ensure constant availability of data recording tools at the facility level., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Cervical cancer continues to generate a significant burden of disease and death in low- and middle-income countries (LMICs). Lack of awareness and poor access to early screening and pre-cancer treatment contribute to the high mortality. We describe here cervical cancer screening outcomes in public health facilities in three states in Nigeria., Methods: We conducted an observational study in 177 government health facilities in Lagos, Kaduna, and Rivers State, Nigeria from January to December 2021, in which we reviewed programmatic data collected through the newly introduced Cervical Cancer Prevention Program. Women who received screening and provided consent were enrolled into the study. Data were extracted from registers in the health facilities using SurveyCTO and descriptive statistical analysis was conducted using StataSE 15 (StataCorp, College Station, TX, USA)., Results: Eighty-three thousand, five hundred ninety-three women were included in the analysis including 6,043 (7%) WLHIV. 67,371 (81%) received VIA as their primary screening while 16,173 (19%) received HPV DNA testing, with 49 (< 1%) receiving both at the same time. VIA positivity was 7% for WLHIV and 3% for general population, while HPV prevalence was 16% for WLHIV and 8% for general population. Following a positive HPV result, 21% of women referred, completed triage examination. 96% of women identified with precancerous lesions, received treatment. 44% of women with suspected cancer were successfully referred to an oncology center for advanced treatment. Following treatment with thermal ablation, seven adverse events were reported., Conclusions: The Program has successfully increased women's access to screening and treatment of precancerous lesions. Almost all women who were eligible for pre-cancerous lesion treatment received it, often on the same day when screened using VIA. However, for women referred for a triage exam or due to suspected cancer, many did not complete their referral visits. More effort is required to ensure HPV positive women and women with suspected cancer are adequately linked to care to further reduce morbidity and mortality associated with cervical cancer in Nigeria. Implementation studies should be conducted to provide insights to improve the utilization of the existing centralized and point of care (POC) platforms to facilitate same day results, and to improve triage and treatment rates., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Nigeria adopted dolutegravir (DTG) as part of first line (1L) antiretroviral therapy (ART) in 2017. However, there is limited documented experience using DTG in sub-Saharan Africa. Our study assessed DTG acceptability from the patient's perspective as well as treatment outcomes at 3 high-volume facilities in Nigeria. This is a mixed method prospective cohort study with 12 months of follow-up between July 2017 and January 2019. Patients who had intolerance or contraindications to non-nucleoside reverse-transcriptase inhibitors were included. Patient acceptability was assessed through one-on-one interviews at 2, 6, and 12 months following DTG initiation. ART-experienced participants were asked about side effects and regimen preference compared to their previous regimen. Viral load (VL) and CD4+ cell count tests were assessed according to the national schedule. Data were analysed in MS Excel and SAS 9.4. A total of 271 participants were enrolled on the study, the median age of participants was 45 years, 62% were female. 229 (206 ART-experienced, 23 ART-naive) of enrolled participants were interviewed at 12 months. 99.5% of ART-experienced study participants preferred DTG to their previous regimen. 32% of particpants reported at least one side effect. "Increase in appetite" was most frequently reported (15%), followed by insomnia (10%) and bad dreams (10%). Average adherence as measured by drug pick-up was 99% and 3% reported a missed dose in the 3 days preceding their interview. Among participants with VL results (n = 199), 99% were virally suppressed (<1000 copies/ml), and 94% had VL <50 copies/ml at 12 months. This study is among the first to document self-reported patient experiences with DTG in sub-Saharan Africa and demonstrated high acceptability of DTG-based regimens among patients. The viral suppression rate was higher than the national average of 82%. Our findings support the recommendation of DTG-based regimen as the preferred 1L ART., Competing Interests: The authors have declared that no competing interest exists., (Copyright: © 2023 Abudiore et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background : The third round of the global pulse survey demonstrated that the abrupt and rapid progression of the COVID-19 pandemic significantly disrupted childhood immunization in many countries. Although Cameroon has reported over 120,000 COVID-19 cases, the reported national childhood vaccination coverage during the pandemic seems to have increased compared to that during the pre-COVID-19 period. Indeed, the first dose of the diphtheria, tetanus, and pertussis-containing vaccine (DTP-1) coverage increased from 85.4% in 2019 to 87.7% in 2020, and DTP-3 coverage increased from 79.5% in 2019 to 81.2% in 2020. The paucity of literature on the impact of COVID-19 on childhood vaccination in COVID-19 hotspot regions poses a challenge in developing a context-specific immunization recovery plan, hence the need to conduct this study. Methodology : We conducted a cross-sectional study using 2019 (pre-pandemic period) and 2020 (pandemic period) district childhood immunization data from the DHIS-2 database, weighted using completeness for each data entry against regional data completeness in 2020. Based on COVID-19 incidence, two hotspot regions were selected, with all districts (56/56) included in the final analysis. The Chi-square test was used to compare DTP-1 and DTP-3 coverage during the pre-pandemic and pandemic periods. Results : In the two hotspot regions, 8247 children missed DTP-1, and 12,896 children did not receive DTP-3 vaccines in the pandemic period compared to the results from the pre-pandemic period. Indeed, there was a significant drop in DTP-1 and DTP-3 coverage of 0.8% ( p = 0.0002) and 3.1% ( p = 0.0003), respectively, in the Littoral Region. Moreover, the Centre Region reported a 5.7% ( p < 0.0001) and 7.6% ( p < 0.0001) drop in DTP-1 and DTP-3 coverage, respectively. Most districts in the hotspot regions reported a decline in childhood immunization access (62.5%) and utilization (71.4%). Indeed, in the Littoral Region, 46% (11/24) and 58% (14/24) of districts experienced decreased vaccination access and utilization, respectively. Meanwhile, 75% (24/32) and 81% (26/32) of districts in the Centre Region experienced a drop in vaccination access and utilization, respectively. Conclusion : This study reported a situation where the national immunization indicators mask the impact of COVID-19 on childhood immunization in heavily hit regions. Therefore, this study presents valuable information for ensuring continuous vaccination service delivery during public health emergencies. The findings could also contribute to developing an immunization recovery plan and informing policy on future pandemic preparedness and response.

Background: As global effort is made towards measles elimination, the use of innovative technology to enhance planning for the campaign has become critical. GIS technology has been applied to track polio vaccination activities in Nigeria with encouraging outcomes. Despite numerous measles vaccination campaigns after the first catch up campaign in 2005, sub-optimal outcomes of previous measles supplemental immunization activities necessitated the use of innovative ideas to achieve better outcomes especially when planning for the 2017/2018 measles vaccination campaign. This led to the application of the use of the GIS technology for the Northern states in 2017/2018 campaign. This study is a report of what was achieved with the use of the GIS in the 2017/2018 measles vaccination campaign in Nigeria., Methods: GIS generated ward maps were used for the microplanning processes for the 2017/2018 measles vaccination campaign. These ward maps had estimates of the target population by settlements, the number and location of vaccination posts ensuring that a vaccination post is sited within one-kilometer radius of a settlement, and the number of teams needed to support the vaccination campaign as well as the catchment area and daily implementation plans. The ward microplans were verified by checking for accuracy and consistency of the target population, settlements, number of teams, vaccination posts and daily implementation work plans using a standard checklist. The ward maps were deployed into use for the measles vaccination campaign after the state team driven validation and verification by the National team (Government and Partners) RESULTS: The Northern states that applied the GIS technology had a closer operational target population to that on the verified microplan than those of the non-GIS technology states. Greater than 90% of the ward maps had all that is expected in the maps - i.e settlements, target populations, and vaccination posts captured, except Kaduna, Katsina and Adamawa states. Of all enumeration areas sampled during the post-campaign survey in states with GIS ward maps, none had a zero-vaccination coverage of the surveyed children, with the exception of one in Borno state that had security issues. In the post campaign coverage survey, the percentage of responses that gave vaccination post being too far as a reason for non-vaccination of children in the Northern zones that used GIS generated ward maps was less than half the rate seen in the southern zones where the GIS microplanning was not used., Conclusion: The use of GIS-generated wards maps improved the quality of ward micro plans and optimized the placement of vaccination posts, resulting in a significant reduction in zero-dose clusters found during the post campaign coverage survey., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Despite the enormous resources committed to the implementation of supplemental immunisation activities in Nigeria, achieving the required coverage (post-campaign survey) to halt the transmission of vaccine-preventable diseases has continued to seem like an impossibility. A vast volume of data is generated and transmitted during mass vaccination campaigns, but this administrative data does not always culminate into improved coverage. The absence of data-informed guidance from stakeholders with long years of experience in planning and implementing mass vaccination campaigns has impeded achieving 95% coverage in measles campaigns in Nigeria. This study reviews the use of data to guide the implementation of the 2017/2018 measles vaccination campaign in Nigeria., Methods: A central coordinating body was formed at the national level with the same replicated in every state. Tools were developed to measure the performance of the different phases and activities required for the implementation of a mass vaccination campaign as recommended in the international guidelines. Stakeholders were engaged to help ensure that feedback provided by the national measles technical coordinating committee was implemented at the lower level., Results: Monitoring and analysis of daily data submission caused a proper spread of senior supervisors, vaccination posts location during the campaign and helped identify areas targeted for mop-up. Although the verification of states' microplan increased the operational target population by 11.2%, the process aided the distribution of resources as appropriate. Maps showing the likely areas that needed additional effort to achieve required coverage with recommendation on the necessary approach to be deployed were transmitted to the states implementing the campaign., Conclusion: The improvement in the use of data to guide implementation of the Nigeria 2017/2018 measles vaccination campaign caused an increase in the number of states that achieved higher coverage in the post-campaign coverage survey., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Globally, supplemental immunization activities (SIAs) are known to be a major strategy for attainment of the global measles elimination goal of less than one measles case per million population within a geographic area by the year 2020. Adequate planning is critical to the success of a vaccination campaign. To achieve a quality SIA implementation for effective interruption of measles transmission, the World Health Organization introduced the SIA Readiness Assessment Tool, which includes the readiness dashboard. It is a strategic planning tool used to ensure critical activities are completed before SIAs. Nigeria implemented a phased measles SIA in 2017/2018 and used the readiness assessment tool in the planning for the campaign. In this article, we report the use of the readiness assessment dashboard in the 2017/2018 measles SIA, we also reviewed its contributions to the outcome of the campaign looking at the post campaign coverage survey results for the states., Methods: We conducted a retrospective review of the readiness assessment dashboard used during the 2017/2018 measles vaccination campaign in Nigeria. The readiness dashboard tool was designed using Microsoft Excel 2016. We reported results in frequencies and proportions using charts and tables., Results: The states with 100% readiness a week prior to the campaign scored a post campaign coverage survey result of 84.6 - 96.5% with just one out of the eight states in this category getting a score below 90%. In the same vein, of the eight states that their readiness score at one week to the campaign was below 85%, six had post campaign coverage survey score of less than 90% with the highest score in this category being 92.3%. Some states with good readiness scores also had poor post campaign coverage survey which has been attributed to other factors other than readiness., Conclusion: The readiness assessment dashboard for the measles vaccination campaign provided a platform for tracking states readiness. It is our view that a link between readiness assessment and coverage should be examined in future studies., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 World Health Organization. Published by Elsevier Ltd.. All rights reserved.)

Purpose: As access to cancer care expands in low-income countries, developing tools to educate patients is paramount. We took a picture booklet, which was initially developed by the nonprofit Global Oncology for Malawi and Rwanda, and adapted it for use in Nigeria. The primary goal was to assess acceptability and provide education. The secondary goals were (1) to describe the collaboration, (2) to assess knowledge gained from the intervention, (3) to assess patient understanding of their therapy intent, and (4) to explore patient's experiences via qualitative analysis., Methods: We piloted the original English booklet at a single site and requested feedback from patients and providers. The booklet was updated; translated into Hausa, Yoruba, Igbo, and Pidgin English; and used at three additional sites. For the three-site cohort, we collected basic demographics, pretest and post-test assessing content in the booklet, and performed a qualitative analysis., Results: The original booklet was widely acceptable and recommended by patients at site one (n = 31) and by providers (N = 26) representing all four sites. In the three-site cohort (n = 103), 94% of patients recommended the booklet. An immediate post-test focusing on when patients should present to care showed a statistically significant improvement in one of the seven questions. Fifty-one percent of the patients (n = 103) knew their treatment intent (curative v palliative). Qualitative analysis highlighted that the patient's thoughts on cancer are dominated by negative associations, although curability and modern therapy are also frequently cited., Conclusion: We adapted an educational booklet to a novel context and had it delivered by local partners. The booklet was widely recommended to future patients. The booklet had an impact on patient's knowledge of cancer treatment, potentially allowing for decreased abandonment., Competing Interests: Abubakar BelloHonoraria: PfizerConsulting or Advisory Role: Pfizer, Roche¸ Merck SeronoSpeakers' Bureau: NCCN Vivienne MulemaEmployment: Mavie Life PharmacyConsulting or Advisory Role: Beyond Logistics Limited Danna RemenEmployment: Allurion (I)Stock and Other Ownership Interests: Allurion (I)Research Funding: Allurion (I) Ami S. BhattEmployment: January.ai (I), Varian Medical Systems (I)Consulting or Advisory Role: Janssen Research & Development, ArcBio, January.ai, Kaleido Biosciences¸ Caribou Biosciences, Guardant Health, BiomXPatents, Royalties, Other Intellectual Property: I have a single patent pending related to SARS-CoV-2 detection in fecal samples. My spouse has several patents pending related to the use of artificial intelligence for blood glucose prediction and radiation therapy planning. Mohana RoyResearch Funding: Varian Medical Systems (Inst)No other potential conflicts of interest were reported.

Background: Nearly 90,000 under-five children die from diarrhoea annually in Nigeria. Over 90% of the deaths can be prevented with oral rehydration salt (ORS) and zinc treatment but coverage nationally was less than 34% for ORS and 3% for zinc with wide inequities. A program was implemented in eight states to address critical barriers to the optimal functioning of the health care market to deliver these treatments. In this study, we examine changes in the inequities of coverage of ORS and zinc over the intervention period., Methods: Baseline and endline household surveys were used to measure ORS and zinc coverage and household assets. Principal component analysis was used to construct wealth quintiles. We used multi-level logistic regression models to estimate predictive coverage of ORS and zinc by wealth and urbanicity at each survey period. Simple measures of disparity and concentration indices and curves were used to evaluate changes in ORS and zinc coverage inequities., Results: At baseline, 28% (95% CI: 22-35%) of children with diarrhoea from the poorest wealth quintile received ORS compared to 50% (95% CI: 52-58%) from the richest. This inequality reduced at endline as ORS coverage increased by 21%-points (P <  0.001) for the poorest and 17%-points (P <  0.001) for the richest. Zinc coverage increased significantly for both quintiles at endline from an equally low baseline coverage level. Consistent with the findings of the pairwise comparison of the poorest and the richest, the summary measure of disparity across all wealth quintiles showed a narrowing of inequities from baseline to endline. Concentration curves shifted towards equality for both treatments, concentration indices declined from 0.1012 to 0.0480 for ORS and from 0.2640 to 0.0567 for zinc. Disparities in ORS and zinc coverage between rural and urban at both time points was insignificant except that the use of zinc in the rural at endline was significantly higher at 38% (95%CI: 35-41%) compared to 29% (95%CI, 25-33%) in the urban., Conclusion: The results show a pro-rural improvement in coverage and a reduction in coverage inequities across wealth quintiles from baseline to endline. This gives an indication that initiatives focused on shaping healthcare market systems may be effective in reducing health coverage gaps without detracting from equity as a health policy objective.

Background: A large proportion of artemisinin-combination therapy (ACT) anti-malarial medicines is consumed by individuals that do not have malaria. The over-consumption of ACTs is largely driven by retail sales in high malaria-endemic countries to clients who have not received a confirmatory diagnosis. This study aims to target ACT sales to clients receiving a confirmatory diagnosis using malaria rapid diagnostic tests (mRDTs) at retail outlets in Kenya and Nigeria., Methods: This study comprises two linked four-arm 2 × 2 factorial cluster randomized controlled trials focused on malaria diagnostic testing and conditional ACT subsidies with the goal to evaluate provider-directed and client-directed interventions. The linked trials will be conducted at two contrasting study sites: a rural region around Webuye in western Kenya and the urban center of Lagos, Nigeria. Clusters are 41 and 48 participating retail outlets in Kenya and Nigeria, respectively. Clients seeking care at participating outlets across all arms will be given the option of paying for a mRDT-at a study-recommended price-to be conducted at the outlet. In the provider-directed intervention arm, the outlet owner receives a small monetary incentive to perform the mRDT. In the client-directed intervention arm, the client receives a free ACT if they purchase an mRDT and receive a positive test result. Finally, the fourth study arm combines both the provider- and client-directed interventions. The diagnosis and treatment choices made during each transaction will be captured using a mobile phone app. Study outcomes will be collected through exit interviews with clients, who sought care for febrile illness, at each of the enrolled retail outlets., Results: The primary outcome measure is the proportion of all ACTs that are sold to malaria test-positive clients in each study arm. For all secondary outcomes, we will evaluate the degree to which the interventions affect purchasing behavior among people seeking care for a febrile illness at the retail outlet., Conclusions: If our study demonstrates that malaria case management can be improved in the retail sector, it could reduce overconsumption of ACTs and enhance targeting of publicly funded treatment reimbursements, lowering the economic barrier to appropriate diagnosis and treatment for patients with malaria., Trial Registration: ClinicalTrials.gov NCT04428307 , registered June 9, 2020, and NCT04428385 , registered June 9, 2020.

In Nigeria, two maternal and neonatal health Networks of Care (NOC) focus on extending the reach and quality of routine and emergency maternal and neonatal health services tailored to the different contexts. This paper uses the four domains of the NOC framework-Agreements and Enabling Environment, Operational Standards, Quality, Efficiency and Responsibility, and Learning and Adaptation-to describe the NOC, highlighting how each developed to address specific local needs. In Northern Nigeria, the NOC were established in collaboration among Clinton Health Access Initiative and the government to reduce maternal and neonatal morbidity and mortality. Health centers and communities in the network were supported to be better prepared to provide maternal and neonatal care, while birth attendants at all levels were empowered and equipped to stabilize and treat complications. The approach brought services closer to the community and facilitated rapid referrals. The NOC in Lagos State extended the reach of routine and emergency maternal and neonatal health services through organically developed linkages among registered traditional birth attendant clinics, private and public sector facilities, the Primary Healthcare Board, and the Traditional Medicine Board. Traditional birth attendants are registered, trained, and monitored by Apex Community Health Officers, whose responsibilities include collection and review of data and ensuring linkages to postpartum services, such as family planning and immunizations. While differing in their approaches, both NOC provide locally appropriate, pragmatic approaches to supporting women birthing in the community and encouraging institutional delivery to ensure that women and their babies have access to timely, appropriate, and safe services.

Introduction: Hypoxemia is a life-threatening condition and is commonly seen in children with severe pneumonia. A government-led, NGO-supported, multifaceted oxygen improvement program was implemented to increase access to oxygen therapy in 29 hospitals in Kaduna, Kano, and Niger states. The program installed pulse oximeters and oxygen concentrators, trained health care workers, and biomedical engineers (BMEs), and provided regular feedback to health care staff through quality improvement teams., Objective: The aim of this study is to evaluate whether the program increased screening for hypoxemia with pulse oximetry and prescription of oxygen for patients with hypoxemia., Methodology: The study is an uncontrolled before-after interventional study implemented at the hospital level. Medical charts of patients under 5 admitted for pneumonia between January 2017 and August 2018 were reviewed and information on patient care was extracted using a standardized form. The preintervention period of this study was defined as 1 January to 31 October 2017 and the postintervention period as 1 February to 31 August 2018. The primary outcomes of the study were whether blood-oxygen saturation measurements (SpO 2 ) were documented and whether children with hypoxemia were prescribed oxygen., Results: A total of 3418 patient charts were reviewed (1601 during the preintervention period and 1817 during the postintervention period). There was a significant increase in the proportion of patients with SpO 2 measurements after the interventions were conducted (adjusted odds ratio [aOR] 5.0; 4.3-5.7, P < .001). Before the interventions, only 13.7% (95% confidence interval [CI]: 12.2-15.3) of patients had SpO 2 measurements and after the interventions, 82.4% (95% CI: 80.7-84.1) had SpO 2 measurements. Oxygen administration for patients with clinical signs of hypoxemia also increased significantly (aOR 5.0; 4.2-5.9, P < .001)-from 22.8% (95% CI: 18.8-27.2) to 77.9% (95% CI: 73.9-81.5)., Conclusion: Increasing pulse oximetry and oxygen therapy access and utilization in a low-resourced environment is achievable through a multifaceted program focused on strengthening government-owned systems., (© 2020 Wiley Periodicals, Inc.)

Integrating seasonal malaria chemoprevention (SMC), recommended by the WHO since 2012 to prevent malaria infection, with nutrition interventions may improve health outcomes and operational efficiencies. This study assessed the effects of co-packaging interventions on distribution coverage, nutrition, and clinical malaria outcomes in northern Nigeria. From August to November 2014, community volunteers delivered sulfadoxine-pyrimethamine and amodiaquine (SP-AQ) door-to-door each month to approximately 7,000 children aged 6-24 months in seven wards of Madobi, Kano State, Nigeria. In three of the wards children additionally received a lipid-based nutrient supplement (LNS-medium quantity), Plumpy Doz. Coverage, adherence, and anthropometric outcomes were assessed through baseline, midline, and endline household surveys. A facility-based case-control study was also conducted to estimate impact on clinical malaria outcomes. Coverage of SP-AQ was similar between arms at 89% (n = 2,409 child-months [88-90%]) in the SP-AQ only arm and 90% (n = 1,947 child-months [88-92%]) in the SP-AQ plus LNS arm (p = 0.52). Coverage of LNS was 83% (n = 2,409 child-months [81-84%]). Whilst there were marked changes in anthropometric status between baseline, midline and endline, these were largely accounted for by socioeconomic status and must be interpreted with care due to possible measurement issues, especially length-based indices. Overall nutritional status of our most robust measure, weight-for-age, does appear to have improved by endline, but was similar in the two study arms, suggesting no additional benefit of the LNS. While the odds of clinical malaria among those who received the intended intervention were lower in each study arm compared to children who did not receive interventions (SP-AQ only OR = 0.23 [0.09-0.6]; SP-AQ plus LNS OR = 0.22 [0.09-0.55]), LNS was not shown to have an additional impact. Coverage of SMC was high regardless of integrating LNS delivery into the SMC campaign. Supplementation with LNS did not appear to impact nutritional outcomes, but appeared to enhance the impact of SP-AQ on clinical odds of malaria. These results indicate that combining nutritional interventions with seasonal malaria chemoprevention in high-risk areas can be done successfully, warranting further exploration with other products or dosing. Trial Registration: ISRCTN 11413895., Competing Interests: Elizabeth Omoluabi (EO) was employed by Akena, the data collection agency contracted using study funding, to oversee data collection activities. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction Nigeria contributes more obstetric, postpartum and neonatal deaths and stillbirths globally than any other country. The Clinton Health Access Initiative in partnership with the Nigerian Federal Ministry of Health and the state Governments of Kano, Katsina, and Kaduna implemented an integrated Maternal and Neonatal Health program from July 2014. Up to 90% women deliver at home in Northern Nigeria, where maternal mortality ratio and neonatal mortality rates (MMR and NMR) are high and severe challenges to improving survival exist. Methods Community-based leaders ("key informants") reported monthly vital events. Pre-post comparisons of later (months 16-18) with conservative baseline (months 7-9) rates were used to assess change in MMR, NMR, perinatal mortality (PMR) and stillbirth. Two-tailed cross-tabulations and unadjusted and adjusted logistic regression analyses were conducted. Results Data on 147,455 births (144,641 livebirths and 4275 stillbirths) were analyzed. At endline (months 16-18), MMR declined 37% (OR 0.629, 95% CI 0.490-0.806, p ≤ 0.0003) vs. baseline 440/100,000 births (months 7-9). NMR declined 43% (OR 0.574, 95% CI 0.503-0.655, p < 0.0001 vs. baseline 15.2/1000 livebirths. Stillbirth rates declined 15% (OR 0.850, 95% CI 0.768-0.941, p = 0.0018) vs. baseline 21.1/1000 births. PMR declined 27% (OR 0.733, 95% CI 0.676-0.795, p < 0.0001) vs. baseline 36.0/1000 births. Adjusted results were similar. Discussion The findings are similar to the Cochrane Review effects of community-based interventions and indicate large survival improvements compared to much slower global and flat national trends. Key informant data have limitations, however, their limitations would have little effect on the results magnitude or significance.

Nigeria is the most populous country in Africa and in 2012 was suffering some of the lowest vaccination rates in the World. A combination of factors had resulted in a dysfunctional immunization cold chain and supply chain. Recognizing that the number of unimmunized children contributed to high levels of under-5-mortality, and that health MDGs would not be attained, Minister of State for Health Mohammed Pate launched a vaccines transformation project in 2013. In partnership with BMGF, GAVI, UNICEF, WHO, other donors and implementing partners the transformation journey has so far taken three years and achieved impressive results. It has though faced challenges along the way and with the financial burden of GAVI graduation facing Nigeria, the economic downturn and the decentralized funding of health services, the results are far from sustained. This paper documents the work undertaken at the Federal level and then highlights specific work undertaken in partnership with Lagos State Government. It identifies the importance of taking an end to end approach and looking at the root causes of weak system performance. The strategy combined simple innovations in how data was captured, recorded and used to drive decision making. It included a comprehensive and systematic approach to cold chain procurement, installation and maintenance with a shift to a culture of active cold chain maintenance that is performing with higher levels of uptime. It also included supply chain redesign at both the Federal and State level. Finally, it involved an institutional transformation at the National Primary Health Care Development Agency (NPHCDA) to establish a data driven Department of Logistics and Health Commodities (DLHC) to manage the many challenges in immunizing 7.5 million children annually. While results have been impressive, there have been many challenges and lessons learned on the way. As Nigeria gets ready for its graduation from GAVI, a robust agile performing cold chain and supply chain will be essential for the good health of Nigeria's children and its economy. The necessary transformation journey has only just begun., (Copyright © 2016 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

There are about 1 million small arms in Nigeria, which contribute to a large number of politically motivated killings. These are mainly sectarian (Christian and Muslim) and ethnic, over land and water rights and the relationship between the activities of companies and the environment. In the Ogoni region of the Niger Delta, with a population of half a million in an area of just over 400 square miles, there are 100 oil wells; the local community is attempting non-violently to clean up their environment. From July 1993 to April 1994 there were about 3,000 cases of gun violence, compared with only two in the previous five years. There were 250 deaths and about 100 amputations. Other forms of violence, including rape, also increased. Routine procedures in the hospitals that remained open were disrupted, there were serious effects on the mental health of the community and many became refugees. It appears that the guns used in this episode were imported by a multinational company for use by the Nigerian police.