SJMLS Volumn 2 No.1 March, 2017 Layout

ISSN: 2536-7153 SJMLS
| SJMLS | Volume 2 | Number 1 | March 2017 |
ISSN: 2536-7153
SOKOTO JOURNAL OF MEDICAL

LABORATORY SCIENCE
(SJMLS)
A Journal of the Faculty of Medical Laboratory Science, Usmanu Danfodiyo University Sokoto, Nigeria
Editor in Chief
Prof. Osaro Erhabor
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Mr. Saheed Ladipo Kakako
Faculty of Medical Laboratory Science Usmanu Danfodiyo University Sokoto P.M.B. 2346, Sokoto, Nigeria.
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SJMLS Volume 2, Number 1 March, 2017 | Page 1

SJMLS ISSN: 2536-7153
Editorial Board Members

Prof. L.S. Bilbis (Dept. of Biochemistry, Faculty of Science, UDU, Sokoto, Nigeria).
Prof. D.M. Bolarin (Dept. of Chemical Pathology Chemical Pathology, CHS, UDU, Sokoto).
Prof. D.E. Agbonlahor (Dept. of Medical Microbiology Ambrose Alli University Ekpoma, Edo State)
Prof. P.O. Anaja (Dept. of Chemical Pathology, Faculty of Medicine Ahmadu Bello University, Zaria).
Prof. B.M. Agaie (Dept of Vet Pharmacology & Toxicology, Fac. of Vet Medicine, UDUS).
Associate Editors
Assoc. Prof. Ifedayo Ajayi (Dept. of Physiology University of Benin, Benin City, Edo State).
Dr. A.S. Mainasara (Dept. of Chemical Pathology Faculty of Medical Laboratory Science UDUS).
Dr. A. S. Kumurya (Dept. of Med. Lab Science, Bayero University, Kano).
Dr. M.H. Yeldu (Dept. of Chemical Pathology Faculty of Medical Laboratory Science UDUS).
Dr. M.K. Dallatu (Dept. of Chemical Pathology Faculty of Medical Laboratory Science UDUS)
Article Reviewers
Prof. S. H. Wara (Dept. of Biochemistry, Faculty of Science, UDU, Sokoto, Nigeria).
Prof. M. G. Abubakar (Dept. of Biochemistry, Faculty of Science, UDU, Sokoto, Nigeria).
Prof. U.Z. Faruq (Dept. of Applied Chem., UDU, Sokoto, Nigeria).
Prof. O.O. Obioma (Department of Histopathology, Abia State University).
Prof. L. Nimzing (Department of Medical Laboratory Science, University of Jos).
Prof. Z.A. Jeremiah (Department of Med. Lab. Science, Niger Delta Uni. Amassoma).
Prof. T.C. Adias (Department of Med. Lab. Science, Niger Delta Uni. Amassoma).
Assoc. Prof. Ifedayo Ajayi (Dept. of Physiology University of Benin, Benin City, Edo State).
Assoc. Prof. N. K. Nnamah (Department of Chem. Path., Nnamdi Azikiwe Univ. Nnewi).
Prof. M. Y. Gwarzo (Dept. of Med. Lab Science, Bayero University, Kano).
Assoc. Prof. A. Emokpae (Dept. of Med. Lab Science, Uni. of Benin).
Prof. S. A. Akuyam (Dept of Chem. Path., Faculty of Medicine ABU, Zaria).
Dr T. Oduola (Department of Chemical Pathology Faculty of Medical Laboratory Science UDUS)
Dr. F.P. Udomah (Department of Haematology and Blood Transfusion Science UDUS)
Dr. S. M. Sahabi (Dept. of Morbid Anatomy & Forensic Med., CHS, UDU, Sokoto).
Dr. J.A. Okwori (Dept. of Med. Micro., Federal College of Veterinary & Med. Lab. Tech., Vom).
Dr F. Ajeneye (Haematology Department, Kings College Hospital NHS Trust London, UK).
Dr. M. Hassan (Dept. of Obstetrics & Gynecology, College of Health Science, UDUS, Sokoto).
Publisher
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Tel: +234-803-308-2298.
Page 2 | SJMLS Volume 2, Number 1 March, 2017

SJMLS VOLUME 2, NUMBER 1 MARCH, 2017
Original /ReviewArticles
S/No Title and Authors Page numbers
1. Original Article
Nuhu, A., Muhammad, K., Nataala. S. U., Ahmad M. G., Garba, I., Muntari,
B., Shuaibu, A. and Machido, D.A. Microbiology of Otitis Media among 6 – 11
Children Attending Clinics within Sokoto Metropolis.
2. Original Article
Helen Ogefere Oroboghae and Isiaka Omolade Osuolale. Risk Factors
Associated with Urinary Schistosomiasis Among School-Age Children in 12 – 20
Owo Local Government Area of Ondo State, Nigeria.
3. Review Article
Nasidi, F. A. and Rogo, L. D. Biology of Hepatitis G Virus: A Review. 21 – 38
4. Original Article
Saheed Opeyemi Usman, Olabisi Oyepero Kalejaye, Ibiwumi Nafisat
Usman, Adebayo Suleiman, Ndumiso Tshuma, Adewale Kayode Ojogbede,
Olusola John Fatunmbi, Gbemiga Peter Olubayo, Sogo Odesanmi and 39 – 48
Jessica Yun. Cardiovascular Risk Factors in South-Western Nigeria: A
WHO Step-Wise Approach.
5. Review Article
Galalain S.M., Bandiya H.M., Galalain A.M. and Mohammed Y. A Review
on the Epidemiology and Burden of Neglected Tropical Diseases. 49 – 57
6. Original Article
Emokpae, M.A. and Nwokedi D.O. Pancreatic enzymes activities in Human 58 – 64
Immunodeficiency virus-1 infected subjects in Benin City, Nigeria.
7. Original Article
Ikpeama Chizoba Anthonia, Ikpeama Chinwe Joy and Ikpeama Osita John,
Ogwuegbu Julie Uchechi. Knowledge, attitude and utilization of
intermittent preventive treatment for malaria among pregnant women 65 – 75
attending antenatal clinic in Usmanu Danfodiyo University Teaching
Hospital(UDUTH) Sokoto.
8. Review Article
Uche, V. N., Ikpeama, O. J., Ogwuegbu, J.U., Ikpeama, C.A., Ikpeama, A. 76 – 89
E. and Ikpeama, C. J. Overview of Safety of Blood Transfusion.
9. Original Article
Saddiq, M., Kankara, A. S. and Dutsin-ma, U. A. Prevalence of Rifampicin
Mono Resistant Mycobacterium tuberculosis among patients Attending 90 – 94
Federal Medical Centre, Katsina, Nigeria.

10. Original Article

Iwumune Ugochi Ijeoma, Ozim S.J. and Ikpeama O.J. Preference of Intra
Uterine Contraceptive Device (IUCD) over other Family Planning methods 95 – 105
among Women of child bearing age in Owerri North L.G.A of Imo State.
Olusola John Fatunmbi, Saheed Opeyemi Usman, Afusat Adesina,
Oluwasogo Sunday Odesanmi, Ibiwumi Nafisat Usman, Adebola Tolulope
Odesanmi, Ndumiso Tshuma, Jessica Yun and Olaiya Paul Abiodun. 106 – 113
Menstrual Training and Hygiene Management Among Adolescents in
South-Western Nigeria: A Cross-Sectional Study.
12. Review Article
Ikpeama Chizoba Anthonia, Ikpeama Chinwe Joy, Ikpeama Osita John and
Ogwuegbu Julie Uchechi. Knowledge of Attitude and Influences of 114 – 123
Alcoholism in Sokoto, Nigeria.
13. Review Article
Omorodion, N.T., Achukwu P.U. and Ebo N. Review on Laboratory 124 – 128
Auditing in Histopathology Laboratory.
Egbe, C.A., Ogefere, H. O. and Okwara, B.U. Hepatitis A virus infection
among HIV patients on highly active antiretroviral therapy in Benin City, 129 – 137
Nigeria.
Mohammad, S., Igbineweka, O.O., Yahya, A.1., Ige, J., Uche, V. N.,
Ikpeama, O.J. and Ogwuegbu, J.U. Malaria in Sokoto: A Case Study of 1 138 – 145
Brigade Medical Centre.
16. Review Artcle
Oyeniyi, Y.J. and Abdulsamad, A. The Use of Antibody as Drug Carrier in 146 – 160
Cancer Chemotherapy.
Ikpeama, E.A., Ikpeama, O.J., Okafor, P.A., Ikpeama, C.A., Ikpeama, C.J.
and Ogwuegbu, J.U. Cystatin C- A Novel Biomarker for Early Detection of 161 – 182
Renal Impairment in Patient With HIV/AIDS.
18. Review Article
Biliaminu, S. A., AbdulAzeez, I. M., Okesina, A. B., Olatinwo, A. W. O., 183 – 191
Omokanye, L. O., Adunmo G. O. Evaluation of Ovarian Reserve in
Assisted Reproductive Facilities; Biochemical and Other Alternatives: Pros
and Cons-A Review Article
Musa Sirajo and Abdullahi Umar. Influence of Tablet Shape, Size and 192 – 197
Colour on Patients Acceptability.


Tanko, Y., Gidado N.M., Mohammed, K.A., Abdulrazak, A. and Yusuf, R.
Effect of Methanol Leaves Extract of Cordia africana on Serum Total
Protein, Albumin, Globulin and some Haematological Indices in Alloxan- 198 – 207
Induced Diabetic Wistar Rats.
Olatunbosun, G.D., Ajeneye, F. and Fredrick, C. A Prospective Study on
Sickle Status and Haemoglobinopathy Awareness in Ijumu Local 208 – 214
Government Area of Kogi State Nigeria.
Tanko, Y., Gidado, N.M., Abdulrazak, A. and Mohammed, K.A. The Effect
of Fermented Cyperus Esculentus Supplement on Erythrocytes and 215 – 222
Leucocytes Indices in Streptozotocin-Induced Diabetic Wistar Rats.
Bello Hali and Lilian Okwubenata Okonkwo. Seroprevalence and Impact of
Hepatitis B e Antigen on Hepatic Transaminases and CD4+ T Lymphocyte 223 – 230
Counts Among Treatment Naïve HIV with HBV Co-infected Subjects in
Sokoto, North Western Nigeria.
AbdulAzeez, I.M., Biliaminu, S.A., Okesina, A.B., Olatinwo, A.W.O.,
Omokanye, L.O. and Adunmo, G.O. Lipid Profile as a Biomarker of 231 – 235
Atherogenicity in Subfertile client with Hyperprolactinemia: A North-
Central Nigerian University Teaching Hospital Experience.
Ahmed, Y., Okwesili, A., Malami, I., Udoma, F. Erhabor, O. Onuigwe, F.
Okwesili, O. Buhari, H. and Emenuga, V. Some Haematological and 236 – 251
Haemostatic Parameters Among Women with Cervical Cancer in Sokoto,
North Western Nigeria.
26. Retraction Notice
Ikpeama O.J., Nwoke, B.E.B., Uche, V. N. (2006). Pattern and Factors
Affecting Weaning Practices among Mothers attending Immunization 252
Services at Comprehensive Healthcare Centre, Nwaorieubi, Mbaitoli L.G.A,
Imo State. Sokoto Journal of Medical Laboratory Science;1(2):91-110.
Instructions to Authors 253 – 254

Sokoto Journal of Medical Laboratory Science 2017; 2(1): 6 – 11

Original Research
SJMLS-2(1)-2017-001
Microbiology of Otitis Media among Children Attending Clinics within
Sokoto Metropolis
Nuhu, A.1, Muhammad, K.1, Nataala. S. U. 1, Ahmad M. G. 1, Garba, I. 1, Muntari, B. 1,
Shuaibu, A.2 and Machido, D.A.3
Department of Med. Microbiology1, Usmanu Danfodiyo University, Sokoto, Department of. Microbiology
and Parasitology Usmanu Danfodiyo University Teaching Hospital, Sokoto 2, Department of Microbiology,
Ahmadu Bello University, Zaria 3.
Corresponding Author: ulnuhu2011@gmail.com/+234-807-459-6714
Abstract active antibiotic against the various bacteria,

Otitis media is the most common source of earaches followed by Ofloxacin and Augmentin. The high
in children of lower socio-economic background. prevalence of otitis media among children may be
Although this condition is a frequent cause of infant due to the inability of the children to take proper care
distress and is often associated with children, it can of themselves, or their being left with maids who are
also affect adults. Diseases of the middle ear not thorough. An additional consideration in
account for approximately one third of visits to selecting antimicrobial drugs should include
paediatricians in this region. This research study considerations of age of the patient, associated
was carried out in other to determine the prevalence illness, history of otitis media, history of antimicrobial
of otitis media and the local aetiological agents of drugs and community susceptibility patterns.
otitis media among children attending clinics within Therefore continued surveillance and investigation
hospitals in Sokoto metropolis. A total of 403 clinical of other oral agents for the treatment of otitis media
patients who were referred to ENT — in the community is required.
Otorhinolaryngology Clinic ranging from babies to
children aged below l4 years old of both gender was Key words: otitis media, otomycosis and
analyzed for causative agents of middle ear antimicrobial resistance
inflammation, and susceptibility pattern of the
isolates. The samples collected on sterile swab Introduction
sticks were inoculated onto prepared dried plates in Otitis media is the most common source of earaches
duplicates and incubated for 18-24 hours aerobically
in children of lower socio-economnic background.
and anaerobically respectively. The cultures were
Although this condition is a frequent cause of infant
identified according to their morphological, cultural,
physiological and biochemical characteristics. A total
distress and is often associated with children, it can
of eight different bacteria and two fungi were also affect adults. The infection in the middle ear
isolated and their distributions are as follows: (where tiny bones pick up vibrations from the
Staphylococcus aureus (27.2%), Pseudomonas eardrum and pass them along to the inner ear) very
aeruginosa (I 4.6%), Proteus species (10.7%), often accompanies a common cold, the flu, or
Escherichia coli (7.8%), Streptococcus pneumornae another type of respiratory infection. This is because
(4.9%), Haemophilus influenzae (2.0%), Klebsiella the middle ear is connected to the upper respiratory
pneumoniae (2.0°/o), Streptococcus pyogenes tract by a tiny channel the eustachian lube (Giebink,
(1.0%), Candida albicans (3.9%) and Aspergillus
et. al., 1989).
species (2.9%). Children 7 years and below were
the most susceptible age group to bacterial otitis
media. Ciprofloxacin was found to be the most

This supporative infection of the middle ear cavity hence guiding the clinician on suitable antibiotics to
ensues when bacteria gain access to the middle ear administer. The clinical complications of otitis
when the normal potency of the eustachian tube is media include chronic effusion, hearing loss
blocked by infection, pharyngitis or hypertrophied cholesteatoma, petrositis- inflammation of the
adenoids. Air trapped in the middle ear is resorbed, petrous region of the temporal bone and intracranial
creating negative pressure in this cavity and extension resulting in brain abscess, subdural
facilitating reflux of nasopharyngeal bacteria. empyema or venous thrombosis other complication
Obstructed flow of secretions from the middle ear to are mastoiditis and neck stiffness which may be an
the pharynx combined with bacterial reflux leads to early sign of complicating meningitis.
infected middle ear effusion. In most tropical Complications that occur in diagnosis are mostly
regions, the prevalence rate is usually higher in the due to the high incidence of antimicrobial resistant
rainy or cold season compared to the dry season strains of some of the aetiological agents, especially
(National Institute on Deafness and other penicillin-resistant Streptococcus pneumoniae as
Communication Disorder NIDCD, 2010). These well as betalactamase producing pathogens. This
varying prevalence rates coincide with the peak research study was carried out in other to determine
occurrence of viral respiratory infections, it also the prevalence of otitis media and the local
occurs more frequently in children with cleft palate etiological agents of otitis media among children
or other craniofacial defects, as well as those with attending clinics within hospitals in Sokoto
enlarged adenoids which cause eustachian tube metropolis.
obstruction or dysfunction (Rosenblut et al., 2006).
The role of allergy is unclear but allergy contributes Material and Methods
to the pathogenesis of otitis media through Sample collection
inflammation and oedema of the nasopharynx and Swab sticks were carefully inserted deeply into the
eustachian tube (Bluestone, 1996). The major risk auditory canal of patients following cleaning the
factors for otitis media are young age, bottle-feeding external area with alcohol avoiding contamination
as opposed to breastfeeding, drinking a bottle in bed, from the external portion while ear fluid was
parental history of ear infection, the presence of a aspirated from patients suffering from chronic otitis
sibling in the home (especially a sibling with a media with effusions, by pulling the patients pinna
history of ear infection), sharing a room with a upwards and outwards to create further access into
sibling, passive exposure to tobacco smoke from the auditory canal middle ear. A total of 403 clinical
parental smoking, and increased exposure to patients who were referred to ear-nose and throat
infectious agents in a daycare centre (Leibovitz et (ENT) Oto-rhinolaryngology Clinic ranging from
al., 2010). Diseases of the middle ear account for babies to children aged below l4years old of both
approximately one third of visits to pediatricians. gender.
Bacterial pathogens recovered from the nasopharynx
do not correlate with bacteria isolated by Isolation and identification of bacterial/ fungal
tympanocentesis (drainage for culture, of fluid from strains
the middle ear using a small gauge needle to The samples collected on sterile swab sticks were
puncture the tympanic membrane). inoculated onto the following prepared and dried
Tympanocentesis and culture of the middle ear plates in duplicates: Mannitol salt agar, MacConkey
exudates is required for accurate identification of’ agar, Blood agar, Chocolate agar, and Sabouraud-
bacterial pathogen presents in the middle ear, and is dextrose agar, inoculated plates were incubated for
useful in neonates, immunocompromised patients 18-24 hours aerobically and anaerobically
and patients not responding to therapy (Kumar et al., respectively. The cultures were identified according
2006). The antimicrobial susceptibility and to their morphological, cultural, physiological and
resistance of the microbes to antibiotics help to biochemical characteristics. The used tests were:
determine the nature of the cause of infection — Gram reaction; Lacto-phenol cotton blue stain;
normal/pathogenic flora or nosocomial infection, production of catalase, cytochrorne oxidase and

hydrogen peroxide; growth at 37 0C and 25 0C in 1 otitis media caused by bacterial pathogens in the
week; acid production from carbohydrates, study conducted was 70.2%, while 6.8% were
production of acid and gas from 1 % glucose. otomycosis (Table I). Bacteriology of otitis media
Methyl red and Voges-Proskauer test in MRVP range from Staphylococcus aureus. Proteus spp.
medium, production of ammonia from arginine; Pseudomonas aeruginosa. Streptococcus
nitrate reduction in nitrate broth; indole production Pneumoniae. Streptococcus pyogenes, Escherichia
in tryptone broth and growth on acetate and citrate coli. Klebsiela pneummoniae, Heamophilus
agar (Ochei and Kolhatkar 2003; Cheesbrough, 2000 influenza, to otomycosis by Candida albicans and
and Koneman, et al., 1992). Aspergillus spps. Table 2, shows the age and gender
-specific distribution. It can be seen that children
Antibiotic Susceptibility Test (Kirby-Bauer Disk below the age of 7 years are more prone to bacterial
Diffusion Method) and fungal otitis media. The next highest prevalence
Antibiotics susceptibility test was carried out on all is seen in the age group of 13 and above with the
isolates using paper disc diffusion technique. A females being generally less prone to infection of
bacterial suspension corresponding to 0.5 the ear than the males.
McFarland turbidity standards was used as inoculum
on Mueller Hinton agar. Antibiotic discs (Biotec The susceptibility pattern of the isolates indicates
Lab. Ltd. UK) used were; Amoxycillin-Clavulanic that Ciprofloxacin was the most active agent
acid (30 µg/disc), Methicilin (25 µg/disc), followed by Ofloxacin and Argumentin. High rates
Erythromycin (15 µg/disc), Tetracycline (30 of resistance to Methicilin and Cotrirnoxazole, often
µg/disc), Cefuraxime (30 µg/disc), Gentamicin (10 in combination were observed in both sets of
µg/disc), Cotrimoxazole (25 µg/disc), isolates. The multiple antibiotic resistant (MAR)
Chloramphenicol (10 µg/disc), Ofloxacin (200 index analysis showed that all the isolates had great
µg/disc), Ciprofloxacin (10 µg/disc), Streptomycin percentage of MAR index value 0.2%. The
(15 µg/disc), Ceftriaxone (30 µg/disc). The plates percentage frequency of MAR index value greater
with the antibiotic discs were incubated at 37 0C for than 0.2% were 57.1% 55.7%, 63.3%, 52.4%,
24 hours (Harley, 2002). Results were interpreted 56.2%, 61.7%, 53.1% and 58.8% of Staphylococcus
according to Clinical and Laboratory Standards aureus, Proteus spp., Pseudomonas aeruginosa,
Institute (CLSI, 2012) guidelines. Multi resistance Streptococcus pneumonia, Streptococcus pyogenes,
(non- susceptibility to at least three families of Escherichia coli, Klebsiela pneummoniae and
antibiotics) and antibiotic resistance index was Heamophilus influenza isolates respectively.
calculated against the tested bacteria (Hala et al., Although isolates exhibiting resistance to multiple
2007). drug classes were rare, resistance to Methicillin,
indicative of extended spectrum beta-lactamase
Results production, was observed in 7% of the infection
The result indicated that the overall prevalence of cases.

Table 1: Prevalence of organisms causing Otitis media in children in Sokoto

(n=403).
Organism Percentage prevalence
Staphylococcus aureus 27.2
Proteus spp. 10.7
Pseudomonas aeruginosa 14.6
Streptococcus Pneumoniae 4.9
Streptococcus pyogenes 1.0
Escherichia coli 7.8
Klebsiela pneummoniae 2.0
Heamophilus influenza 2.0
Candida albicans 3.9
Aspergillus spp. 2.9
Table 2: Distribution of Otitis media among children in Sokoto State by age group and gender specific
Age group Gender
(years) No. Male infected No. Female infected
≤0.5 9 4
≤1 17 11
≤2 31 16
≤3 22 8
≤4 18 7
≤5 29 16
≤6 28 21
≤7 25 18
≤8 13 5
≤9 13 14
≤10 13 7
≤11 7 2
≤12 4 3
≤13 10 11
≤14 15 8

No=number
Figure 1: Percentage of frequency MAR index value ≥0.2 (%)
Discussion
Several reports have indicated that some bacteria, In this study, the incidence of otitis media was
viruses and fungi as causes of otitis media higher in children of aged below 6 years than the
(Henderson and Tsai, 2001). The most dominant older children. This finding is consistent with report
organism isolated was Staphylococcus aureus with a by Sophia et al. (2010). This may be due to the
frequency of occurring of 27.2%. This high inability of the children to take proper care of
incidence of Staphylococcus aureus is mainly from themselves, or their ward being left with maids who
the outer ear as normal flora, but disseminates into are not thorough. It could also be due to the different
the middle ear as a pathogen. It is transferred by air anatomy of the ear of a child, they have a shorter
and reaches the ear as droplets from the respiratory and more horizontal Eustachian tube. It can also be
tract or as dry particles from the body surface deduced from the study that the incidence of otitis
(Giebink et al., 1989). The next common pathogen media is higher in males than in females. This
was Pseudomonas aeruginosa (14.6%). Kumar and finding is in agreement with previous reports
colleagues (2006), reported this opportunistic (Hendersen, 2001 and O’Nell, 1999) which
aerobic Gram-negative bacillus as common cause of indicated that associated genetic and environmental
hospital-acquired infections, and cause external factors were common causes. It could also be due to
otitis in healthy individuals and severe supportive their dynamic and rascal nature in contrast with their
external otitis in diabetics with 12.7% and 16.7% female counter parts which attributes the
caused otitis media in males and females restlessness of tympanic membrane in the middle
respectively with 9.7% discharging cases. ear.

The results of antimicrobial susceptibility tests Koneman, E.W., Allen, S.D., Janda, W.M.,
carried out showed that many of the organisms Schreckenberger, P.C. (1992). Color Atlas and
isolated were sensitive to Ciprofloxacin, Ofloxacin, Textbook of Diagnostic Microbiology. 5th ed.
Gentamicin, and Streptomycin in that order. An New York, USA: J.B. Lippincott Company:
additional consideration in selecting antimicrobial 348-353.
drugs should include considerations of age of the Kumar, V., Abbas, A.K. and Fausto, N. (2006). Ear;
patient, associated illness, history of otitis media, Diseases of Organ Systems. In: Robbins and
history of antimicrobial drugs and community Cotran Pathologic Basis of Disease, 7th Ed.
susceptibility patterns. The high frequency of India: W.B. Saunders, Publication: 1918.
multiple antibiotic resistant isolates observed in this Leibovitz, E., Dogan, R., Leiberman, A., Chaletz, G.
study most probably reflect the ease of access and and Porat, N. (2010). Antibiotic treatment in
the extensive use of these antibiotics in this acute otitis media promotes super infection
environment and probably across the entire country. with resistant streptococcus pneumonia carried
The reason behind this may be due to excessive use before initiation of treatment. Journal of
of antibiotics in treatment of infectious bacterial Infectious Diseases; 183: 880-886.
diseases as well as due to environmental cross National Institute on Deafness and other
contamination through other risk factors such as Communication Disorder (NIDCD) (2010). Ear
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investigation of other oral agents for the treatment of Ochei, J. and Kolhatkar, A. (2008). Medical
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New Delhi, McGraw-Hill Ltd: 991-1026.
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Original Research
SJMLS-2(1)-2017-002
Risk Factors Associated with Urinary Schistosomiasis Among School-
Age Children in Owo Local Government Area of Ondo State, Nigeria.
Helen Oroboghae Ogefere*1 and Isiaka Omolade Osuolale1,2
Department of Medical Science, School of Basic Medical Sciences, College of Medical Sciences, University of
Benin, Benin City Nigeria 1, Department of Medical Microbiology, Federal Medical Centre, Owo 2.
* Author for Correspondence: helenogefere@yahoo.com, helen.ogefere@uniben.edu
Abstract associated with ABO blood group (p= 0.2913) and

Urinary schistosomiasis is hyperendemic in many Rhesus D blood group (p=0.3087) of the children. All
countries in Africa including Nigeria. This study was infected children were of AA haemoglobin
carried out to determine the risk factors and electrophoretic pattern. The current treatment/
prevalence of urinary schistosomiasis among control programme of the Ondo State Government
school-age children in Owo Local Government Area should be intensified with emphasis geared towards
of Ondo State, Nigeria. A total of 427 school children creating awareness among people who are at a high
aged 5-19 years were studied. Structured for urinary schistosomiasis.
questionnaire was used to obtain risk factors and
socio-demographic characteristics from the subjects. Keywords: Urinary schistosomiasis, Risk factors,
Freshly voided terminal urine samples were School children, Ondo State, Nigeria.
collected from the children, and 5ml of blood was
also withdrawn for haematological analysis. The
freshly voided terminal urine samples were analyzed
Introduction
for Schistosoma haematobium ova using
Schistosomiasis is a neglected parasitic tropical
microscopy. Haemogblobin concentration was
determined using the Sysmex KX-21 haematology
disease caused by a trematode of the genus
analyzer (Sysmex Corporation, Kobe, Japan). The schistosoma and it is one of the major public health
blood group and haemoglobin electrophoresis were problems facing developing countries (Ossai et al.,
done using the conventional manual method. The 2014). Schistosomiasis is one of the most common
result showed that 12 (2.81%) of the children were parasitic infections in the world, ranking second
infected with Schistosoma haematobium. Urinary after malaria in terms of socio-economic and public
schistosomiasis did not differ significantly by gender health importance, especially in rural areas of
(p=0.3087) and age (p=0.0734). Farming as parents’ developing countries (Kings, 2009; Engel et al.,
occupation, presence of stream in the community
2002). Schistosomiasis is estimated to affect 249
and presence of stream close to school where risk
million people worldwide, of which at least 224
factors for acquiring urinary schistosomiasis. There
was significant association of urinary
million affected people live in sub-Saharan Africa.
schistosomiasis and clinical manifestation of blood The disease is responsible for mortality of an
in urine (OR= 16.319, 95% CI=4.899.54.364, estimated 280,000 people each year in the African
p<0.0001) and difficulty in urination (OR=54.515, region alone (Geleta et al., 2015 and CDC, 2011).
95% CI= 6.919, 429.50, p< 0.0001) among the Africa accounts for over 85% of schistosomiasis
subjects. Urinary schistosomiasis was significantly burden (Ossai et al., 2014).
associated with anaemia (p=0.0200) in the infected
pupils. Urinary schistosomiasis was not significantly

The main disease causing schistosome species are Study population

Schistosoma haematobium (S. haematobium), S. A total of 427 children consisting of 251 males and
mansoni, S. japonicum, S. mekongi and S. 176 females with age ranging from 5 to 19 years
intercalatum (Gryseels et al., 2008). S. were randomly recruited for this cross-sectional
haematobium is the aetiologic agent of urinary study from 10 schools in Owo Local Government
schistosomiasis and it is most prevalent in Africa area of Ondo State, Nigeria. A structured
(Ogbonna et al., 2012 and Sam-Wobo et al., 2011). questionnaire was used to collect information on
Nigeria is the most endemic country in the world for demography and risk factors. Clinical signs and
urinary schistosomiasis with an estimated 25.83 symptoms were obtained with help of a Physician.
million people infected (WHO, 2002 and Okoli and Informed consent was obtained from the
Odabido, 1999). In Nigeria, the prevalence of parents/guardians of the children prior to specimen
urinary schistosomiasis in both rural and urban collection. The study was approved by the
communities ranges from 2% to 90% and occurs Department of Health Services of Owo Local
more among the poor marginalized set of people Government Council.
(Okwori et al., 2014). School age children are more
vulnerable to urinary schistosomiasis infection due Specimen collection and processing.
to frequent water contact (Bala et al., 2012; Deribe Urine and blood specimens were collected from
et al., 2011). In children, the disease has been each child. Freshly voided terminal urine specimen
associated with growth retardation, reduced was collected from each participant in a clean pre-
cognitive ability, poor physical fitness and irregular labeled universal container. About 5 ml of venous
school attendance (King, 2010; Opara et al., 2007 blood was also collected from each participant and
and Albonico et al., 2006). To our knowledge, there dispensed into ethylene diamine tetra acetic acid
is no study on urinary schistosomiasis in Owo Local (EDTA) container and mixed. Each well-mixed
Government Area of Ondo State, Nigeria. Against urine sample was dispensed into a pre-labeled 10 ml
this background, this study aimed to determine the tube and centrifuged at 3000 revolutions per minute
prevalence and risk factors for urinary for 5 minutes. The supernatant was discarded and
schistosomiasis in Owo Local Government Area, the deposit was re-suspended. A drop of the re-
Ondo State, Nigeria. suspended urine deposit was placed on a slide and
covered with a cover slip. The preparation was
Materials and Methods examined microscopically using x10 and x40
Study area objective lenses for the presence of the ova of S.
This study was carried out from March 2015 to haematobium. ABO and Rhesus D blood group were
November 2015 at Owo Local Government Area in determined as previously described (Enosolease and
Ondo State, Nigeria. Owo has a total population of Bazuaye, 2008). Briefly, a drop of each participant’s
420,000, mainly belonging to Yoruba-Owo culture blood was placed on three separate areas on a clean
and language group. The area is divided into white tile. Each drop of blood was mixed with a
communal areas (peasant farming households), areas drop of commercially prepared antiserum A, B and
of small and large scale farming and semi urban D respectively and observed for agglutination.
centers (Ijebu Owo and Oke Owo). There are 15 Haemoglobin concentration was determined using
small streams, one large river and one big dam. The an autoanalyser – Sysmex KX-21 (Sysmex
people often visit these streams during their leisure Corporation, Kobe, Japan). Anaemia was defined a
hour to hunt for fishes and other water animals. The haemoglobin concentration <11g/dl (Akinbo et al.,
seasons are well defined with a hot dry season from 2009). Haemoglobin electrophoresis was carried out
January to March, hot wet season from April to using cellulose acetate paper and Tris buffer as
June, cold wet season from July to October and cold previously described (Ochei and Kolhatkar, 2008).
dry season from November to December.

Statistical analysis History of blood in urine (OR=16.319

The data obtained were analyzed with Chi square 95%CI=4.899, 54.364; p<0.0001), history of
(X2) test and odd ratio analysis using the statistical difficulty in urination (OR=54.515 95%CI=6.919,
software INSTAT® (GraphPad Software Inc., La 429.50; p<0.0001) and anaemia (OR= 4.329 95%
Jolla, CA, USA). Statistical significance was set at CI=1.358, 13.796; p=0.0200) were clinical
p≤ 0.05. manifestations significantly associated with urinary
schistosomiasis infection (Table 3).
Results
A total of 12 (2.81%) out of the 427 children had The ABO blood group of the children studied, did
laboratory-confirmed urinary schistosomiasis in this not significantly affect the prevalence of urinary
study. Gender (p=0.3087) and age (p=0.0734) did schistosomiasis (p=0.2913). However, ABO blood
not significantly affect the prevalence of urinary group O individuals had the highest prevalence
schistosomiasis, though males 9(3.72%) had higher (4.04%) of infection. Of those infected, Rhesus D
prevalence and age group 14 – 16 years had the negative pupils had a higher prevalence (8.33%) of
highest prevalence (8.62%) of infection (Table 1). urinary schistosomiasis although, Rhesus D blood
group was not significantly associated with
Among the risk factors, it was found that the prevalence of urinary schistosomiasis (OR=3.482,
occupation of parents of all Schistosoma 95% CI=0.719, 16.874; p=0.3087). All 12 infected
haematobium infected children was farming. The children with urinary schistosomiasis in the study
presence of streams in the community (OR=6.341 were of AA haemoglobin electrophoretic pattern
95%CI=1.924, 20.894; p=0.0030) and presence of (Table 4).
streams close to school (OR=11.185 95%CI=0.657,
190.53; p=0.047) were significantly associated with
the prevalence of acquiring schistosomiasis (Table
2).
Table 1: Effect of age and gender in the distribution of urinary Schistosomiasis among children.
Characteristics No. Test No. Infected (%) OR 95%CI p-Value
Gender
Male 251 9(3.72) 3.482 0.7185,16.874 0.3087
Female 176 3(1.71)
Total 427 12(2.81)
Age (Years)
5-7 62 2(3.23) 0.0734
8-10 145 3(2.07)
11-13 150 2(1.33)
14-16 68 5(8.62)
17-19 2 0(0.00)
OR = Odd ratio; CI = Confidence interval

Table 2: Risk for urinary Schistosomiasis in children.

Characteristics No. Test No. Infected OR 95%CI p-Value
(%) (%)
Occupation of Parents
Farmers 377(88%) 12(3.18) 0.5172
Civil Servant 50(12%) 0(0.00)
Presence of Streams in
the Community
Yes 371(87%) 7 (1.89)
No 56(13%) 5(10.87) 6.341 1.924,20.894 0.0030
Use of nearby streams for

domestic activities
Yes 250(59%) 7 (2.80)
No 177(41%) 5 (2.99) 0.933 0.291,2.992 0.9076
Presence of stream close

to school
Yes 292(63%) 12 (4.11)
No 135(37%) 0.(0.00) 11.185 0.657,190.53 0.0477
Playing or bathing in
streams
Yes 252(59%) 10 (3.97)
No 175(41%) 2 (1.21) 7.485 0.957,58.568 0.0517
Table 3: Distribution of urinary Schistosomiasis in relation to clinical manifestation.

Characteristics No. Tested No. Infected OR 95%CI p-Value
(%)
History of blood in
urine
Yes 378 5 (1.32) 16.319 4.899,54.364 <0.0001
No 49 7(17.95)
Family history of blood
in urine
Yes 35 0 (0.00) 1.675 0.096,29.130 0.7866
No 392 12(3.06)
History of difficulty in
urination
Yes 79 11 (13.92) 54.515 6.919,429.50 <0.0001
NO 348 1 (0.30)
History of lower
abdominal pain
Yes 142 7 (4.93) 2.800 0.872,8.989 0.1357
No 285 5 (1.82)
Anaemia
Yes 82 6 (7.32) 4.329 1.358,13.796 0.0200
No 345 6 (1.74)

Table 4: Effect of ABO and Rhesus D blood groups, and haemoglobin electrophoresis on the prevalence
of urinary schistosomiasis.
Characteristics No. Test No. Infected OR 95%CI p-Value
(%) (%)
ABO blood group
A 104 3 (2.88) 0.2913
B 71 0 (0.00)
AB 19 0 (0.00)
O 233 9 (4.04)
Rhesus D blood group
Rhesus D positive 393 10 (2.54) 3.482 0.719,16.874 0.3087
Rhesus D N 34 2 (8.33
Haemoglobin
Electrophoresis
AA 312 12 (3.85)
AS 111 0 (0.00)
SS 2 0 (0.00)
AC 2 0(0.00)
Discussion treatment/control programmes on schistosomiasis by
This study showed that 12 (2.81%) of the 427 the Ondo State Government (Ondo State Primary
subjects were infected with urinary schistosomiasis. Health Care Development Board, 2015).
This prevalence is lower compared to previous
reports from other Local Government Areas in Ondo In relation to gender, male subjects 9 (3.72%) had a
State. Oniya and Odaibo (2006) reported a higher prevalence of Schistosoma haematobium
prevalence of 55%, Oniya and Jeje (2010) 53.1%, infection than females 3 (1.71%), though gender did
Oniya et al. (2013) 18% and also in Ile- not significantly affect the prevalence of urinary
Oluji/Okegbo LGA, a prevalence of 14.3% was schistosomiasis (p=0.3089). This result is
reported among primary school pupils by Ajakaye comparable with findings in previous reports
(2015). The observed infection rate is also lower (Okwori et al., 2014; Ugbomoiko et al., 2010; Biu et
when compared with reports from other neighboring al., 2009 and Ureke et al., 2006). In contrast, Ekpo
states in the South West region of Nigeria. A et al., (2010) and Nkegbe (2010) separately reported
prevalence of 52.4% was reported by Akinwale et a not significantly higher prevalence among females
al. (2009) in Ogun State. In Ile-Ife, Babatunde and compared to males in Nigeria and Ghana
colleagues (2013) reported infection rate of 48.2%. respectively. The higher prevalence among males
Infection rate was also lower in this study when recorded in our study could be as a result of diverse
compared with studies done in other regions in outdoor activities engaged by male children which
Nigeria; Amaechi (2014) in Abia State, South may have exposed them more to cercariae infected
Eastern Nigeria recorded rate of 53.8%. Bala et al., water. In the study community, fathers engage their
(2012) recorded an infection rate of 74% in Gasua. male children in their profession which is farming
A prevalence rate of 14.5% was reported in and fishing.
Maiduguri in North East Nigeria by Joseph et.al.
(2010) and Okwori et al., (2015) reported 44.3% in The insignificantly higher prevalence of 8.62%
North Central Nigeria. Dawet et al. (2012) reported among the age group 14-16 years in this study
among residents of Jos North Local Government agrees with the findings of Dakul et al. (2001) and
Area, a lower infection rate of 2.07%. The low Okwori et al. (2014). This age group is very active
prevalence rate (2.81%) recorded in this study may and derives pleasure from playing around rivers and
be an outcome of increased awareness as well as streams where the human cercaria ratio is high. In

contrast, Uneke et al., (2006) reported a decreasing of blood in their urine. This means that visible blood
prevalence of Schistosoma haematobium infection in urine is not a reliable and accurate clinical
with increasing age. manifestation for diagnosing urinary schistosomiasis
as previously suggested (Ogbonna et al., 2012).
The occupation of parents was not significantly
associated with urinary schistosomiasis, though the Anaemia among infected children was statistically
parents of all infected children were farmers. This significant to clinical manifestation of urinary
agrees with similar study in Ethiopia (Geleta et al., schistosomiasis (p=0.0200). This is in agreement
2015), where infected children participated with with other reports (Okwori et al., 2015 and
their parents in farming activities. This may be due Igbeneghu and Oliseodinaka, 2014). Anaemia
to lack of awareness about risk factors of urinary caused by Schistosoma haematobium infection was
schistosomiasis. Poor protective role of parents due as a result of chronic blood loss as ova penetrate the
to illiteracy and poor awareness of urinary urinary tract and severe infection is characterized by
schistosomiasis has been reported previously iron loss and red cell lysis, resulting in iron
(Ugbomoiko et al., 2010) as drivers of the infection deficiency anaemia (Igbeneghu and Oliseodinaka,
in local communities. 2014).
The prevalence of urinary schistosomiasis and The effect of ABO blood group of the infected
presence of streams in the community and /or children on the prevalence of urinary
presence of stream close to school of the pupils had schistosomiasis was not statistically significant
significant association (p=0.0111 and 0.0380 (p=0.2913). The same observation was reported
respectively). This may be as a result of close and previously (Igbeneghu and Oliseodinaka, 2014;
easy access of the children to streams in the Oniya and Jeje, 2010 and Kassim and Ejezie, 1982).
community and streams close to schools. It is This implies that no particular ABO blood group
worthy to note that though higher prevalence of predisposes an individual to Schistosoma
urinary schistosomiasis was recorded among haematobium infection. However, most of the
children who played and bathed in streams as infected children in our study were of ABO blood
against those who did not, the association was not group O. This is contrary to the findings of Deribew
significant (p=0.0517). Similar results were reported et al., (2012) and Igbeneghu and Oliseodinaka
in Ethiopia (Galeta el al., 2015). Also, use of (2014) who recorded significantly higher severity of
nearby streams for domestic activities was urinary schistosomiasis among ABO blood group A
statistically not significant (p=0.907) in relation to children.
urinary schistosoma infection. These imply that long
duration of hours to contact with infected water is a There was no significant association between
relevant risk factor for exposure to cercariae urinary schistosomiasis infection and prevalence of
infection rather than frequency of water contact Rhesus D blood group (p=0.3087), though Rhesus
(Hassan et al., 2012). blood group D negative participants had a higher
prevalence (8.33%). There is paucity in literature of
In this study, there was significant (p< 0.0001) the effect of Rhesus D blood group and
association between urinary schistosomiasis and haemoglobin electrophoretic pattern on prevalence
history of blood in urine (haematuria). This finding of urinary schistosomiasis. It is interesting to note
is in agreement with previous report that indicated a that all the subjects infected with urinary
strong association between haematuria and schistosomiasis in this study were of AA
microscopic detection of ova of Schistosomia haemoglobin electrophoretic pattern.
haematobium infection (Ogbonna et al., 2012).
Children without current clinical history of blood in Conclusion
their urine had a higher prevalence of 17.95% as This study has shown a prevalence rate of 2.81%
against 1.32% prevalence of those who had history urinary schistosomiasis among school children in

Owo Local Government Area, Ondo State, Nigeria. Bala, A.Y., Ladan, M.U. andMainasara, M. (2012)).
Farming, presence of streams in the community and Prevalence and intensity of urinary
presence of stream close to school of children were schistosomiasis in Abama village, Gusau,
risk factors for school children acquiring urinary Nigeria: a preliminary investigation. Science
schistosomiasis. Clinical manifestations of the World Journal; 7 (2):1- 4.
infection in infected children include history of Bui, A.A., Kolo, H.B. and Agbadu, E.T. (2009).
blood in urine, difficulty in urination and anaemia. Prevalence of Schistosoma haematobium
All infected children were of AA haemoglobin infection in schools aged children of Konduga
electrophoretic pattern. The treatment/control Local Government Area, North-eastern Nigeria.
programme of the Ondo State Government to International Journal Biomedical Health
eradicate urinary schistosomiasis should be Science; 5:181-184.
encouraged and intensified in the studied CDC (2011). The burden of schistosomiasis.
community. Available:
http:/www.cdc.gov/globalhealth/ntd/diseases/sc
Acknowledgments histo_burden.html. Accessed: 13 February
Authors are grateful to Ondo State Ministry of 2015.
Education, Owo Local Government Education Dakul, D.A., Onwuliri, C.O.E., Anyanwu, G.I. and
office, all Head Teachers, parents/guardians and the Imander, N.G. (2001). A longitudinal study of
subjects for approval and logistical support. Schistosoma haematobium infection in Quaan-
Pan Local Government Area of Plateau State.
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Original Research
SJMLS-2(1)-2017-003
Biology of Hepatitis G Virus: A Review
Nasidi, F. A.1 and Rogo, L. D.1*
Department of Medical Laboratory Science, Faculty of Allied Health Sciences, College of Health Sciences,
Bayero University, Kano. P.M.B. 3011, Kano – Nigeria 1.
*Corresponding Author: ldrogo.med@buk.edu.ng/+234-803-964-9234/ +234-802-256-9132
Abstract Introduction
Hepatitis G virus (HGV) was discovered in the study Hepatitis G virus (HGV), was discovered by two
of cases of hepatitis non-A, non-B, non-E. It is a
independent groups of investigators in the study of
linear, icosahedral, monopartite, enveloped, single
cases of hepatitis non-A, non-B, non-E (Linnen et
stranded positive sense (ssRNA) virus belonging to
the Flaviviridae family, a member of
al., 1996 and Simons et al., 1995).
the Pegivirus genus and Hepatitis G virus (HGV)
type specie. It is a blood-borne infectious pathogen The discovery of a new viral agent associated with
without ethnic, socioeconomic, gender, age or liver diseases has attracted considerable attention
geographic boundaries. Approximately, 750 million due to the fact that there are hepatitides of unknown
people are actively infected (viraemic) and an etiology. This determined the urgency of
estimated 0.75–1.5 billion people have evidence of investigations aimed at comprehensively studying
prior HGV infection. HGV RNA is detected in the properties of the virus, its association with liver
patients with acute (35%) and chronic (39%)
disease and infection rates in different countries of
hepatitis of unknown etiology. HGV RNA is also
the world. In 1966, the 34-year-old Surgeon G.
found in some patients with acute or chronic
hepatitis, fulminant hepatitis patients, and chronic
Barker (GB) fell ill with acute hepatitis of moderate
hepatitis C patients (21%), intravenous drug users enzymatic activity and three-week icteric period.
(33%), patients on hemodialysis (3-56%), multiple Patient blood taken on icteric day 3 was used for
blood transfused patients (58%) and hemophiliacs intravenous inoculation of non-human primates
(18%). Several but not all studies have suggested (bare-faced Marmosets, the Callithricidae family).
that co-infection with HGV slows the progression of Hepatitis was recorded in all animals when four
HIV disease. The mechanism responsible for the monkey-to-monkey passages were performed. The
development of HGV-induced hepatitis is not clear findings suggested that the cause of this hepatitis
so far. The pattern of its genetic evolution, strange
was a yet unidentified viral agent that was named
properties and functional profile, its complicated
GBV. Investigations of the GB agent recommenced
connection with the host are all subjects that are far
from a complete comprehension. The aim of this
two and a half decades later when new methods for
review was to present the current view in the biology qualitative viral analysis and recognition evolved.
and clinical significance of Hepatitis G virus which Serum taken in the acute stage of hepatitis from
may be beneficial for future studies. infected Marmosets was found to contain two viral
genomes:
Key words: biology, Hepatitis G virus, HIV,
pathogenesis, epidemiology. GBV-A and GBV-B belonging to closely- related
viruses of the Flaviviridae family. Both viruses were
able to replicate in the Marmosets, but only GBV-B
caused hepatitis. Attempts to detect GBV-A or

GBV-B in human beings failed. A third virus GBV- 12%) have been described (Tucker and Smuts, 2000
C was soon isolated from patient material by means and Okamoto et al., 1997). Investigations dealing
of specially designed primers to the conserved part with the classification of GBV-C were conducted by
of the NS3 region of the viruses GBV-A, GBV-B measuring restriction fragment length
and HCV. GBV-C was assigned to the GBV group polymorphisms. The isolates from West Africa are
as it was slightly similar to GBV-B protein in referred to as genotype 1 where in 2 subtypes: 1a
immunoassays and largely identical to GBV-A in and 1b are identified. Genotypes 2a and 2b are more
nucleotide sequence. GBV-C proved to be frequently detected in North America and Europe;
genetically related to another independent isolate genotypes 3, 4 and 5 are more common in Asia,
that had been originally called HGV. They are South-Eastern Asia, and South Africa, respectively.
virtually indistinguishable in the routine diagnosis Phylogenetic analysis of genomic nucleotide
by polymerase chain reaction (PCR). Since the signs sequences of the 5' and NS5 regions made (Novikov,
of HGV became more commonly detected in 2000) has established that the HGV isolate
patients with hepatitis and persons at risk for belonging to viral genotype 2 circulates in Russia,
parenteral hepatitis, hepatitis G was considered to be Kazakhstan, Kyrgyzstan, and Turkmenistan.
an independent hepatotropic entity. Experiments Analysis of HGV 5'-untranslated region sequences
infecting chimpanzees with the HGV RNA- revealed a new sixth genotype of virus in Indonesia
containing plasma taken from patients with chronic (Muerhoff et al., 2006). In addition to genomic
hepatitis G (CHG) yielded rather unexpected results. variability in different HGV isolates, some authors
All the infected animals developed persistent and propose HGV genomic variability within one isolate
continuing viremia. However, no case showed a rise suggesting that there are quasispecies, thereby
in the levels of indicator enzymes or detectable emphasizing their similarity with HCV (Viazov et
abnormal liver tissue changes in liver biopsy al., 1997). But, the opponents of this theory argue
specimens taken weekly throughout the follow-up. that based on the absence of a hyper variable region
Javan Macaques were also observed to have viremia in the E2 gene, the presence of quasispecies is
without signs of liver damage. By contrast, signs of impossible (Stapleton et al., 2004 and Mikhailov,
hepatitis in the form of hyperenzymaemia and 1997).
necrotic and inflammatory changes in the liver
appeared by day 30 after inoculation of the Functional Genomic of HGV Structure
Marmosets that had received the same HGV- The genome of the virus is represented by a linear,
containing materials (Balayan and Poleshchul, single stranded, positive, with 9.4kb RNA in length
1998). (Nakao et al., 1997). The HGV genome is similar to
hepatitis C virus (HCV) RNA in its organization,
Further serological screening-based investigations that is, the structural genes are located at the
have indicated that the HGV isolate is of widespread genomic 5' region and non-structural genes are at the
occurrence; however, there is no evidence for an 3' end (Kim and Fry, 1997) as shown in figure 1 and
association of viremia with the development of some 2. The untranslated region at the 5' end may serve as
known diseases, such as hepatitis (Maidana et al., an internal ribosomal embarkation site, which
2005). ensures translation of a RNA coding region (Bassit
et al., 1998). The extent of the genome in different
Taxonomy and Genotypic Variety of GBV-C viral isolates ranges from 9103 to 9392 nucleotides
HGV virus, like GBV-A, GBV-B, and HCV, (Leary et al., 1996 and Schaluder et al., 1995). An
belongs to the Flaviviridae family. Comparison of open reading frame carries information on the virus-
the genomes of GBV-C, GBV-A, GBV-B, and HGV specific polypeptide consisting of 2873-2910 amino
has demonstrated that their RNA does not bear a acid residues.
more than 32% similarity, thereby supporting the
hypothesis that these viruses are independent. Five HGV RNA codes for two structural proteins (E1 and
HGV genomes (the divergence between them was E2) which are envelope proteins. Unlike HCV, the

proportion of glycosylated E2 is much lower in viral nucleocapsid is still to be determined as the

HGV. It has a total of three potential N- genomic region coding for core proteins has not
glycosylation sites as compared with HCV E2, been identified yet (Marmor, 2006).
which has eleven sites. The complete structure of
Figure 1: A generalized schematic representation envelope in which the E1 and E2 envelope

of Flaviviridae – HGV: Viral particles are glycoproteins are embedded. Apolipoproteins that
composed of a nucleocapsid containing the viral are associated with particles are represented
RNA surrounded by a host cell-derived lipid (Fénéant et al., 2014).

Entry factors Replication factors

Membranous web
N-ter C E1 E2 NS2 NS3 NS4B NS5A NS5B C-

ter.
NS4A
Envelope p7 Protease, Helicase,
glycoproteins Protease NTPase, NS2 RNA –
scaffold protease cofactor
RNA binding, dependant
for
Capsid protein Switch replication/ RNA-
multiple
NS3 protease assembly polymerase
interaction
s cofactor
Viroporin, pH alteration of the
secretary pathway, Encapsidation
and envelopment Proteases responsible for the polyprotein processing:
host SPP, host SP, NS2/3, NS3/4A
Figure 2: A generalized genomic structure of beneficial effect may be related to action of several
Flaviviridae – HGV: the structural proteins core HGV viral proteins including
(C), E1 and E2 from the N-terminal third of the NS5A phosphoprotein and E2 envelope protein
polyprotein, and the non-structural proteins p7, (Giret and Kallas, 2012). A study by Herrera and
NS2-5B from the C-terminal part. SP, signal Colleagues (2009), highlighted that the E2 (269-
peptidase; SPP, signal peptide peptidase (Vieyres 286) sequence interacts with the target fusion
et al., 2014). peptide of HIV-1 and modifies its conformation.
HGV E2 was shown to decrease cellular membrane
Five non-structural proteins: NS2, NS3, NS4b, fusion and interfere with HIV-1 infectivity in a
NS5a, and NS5b with molecular weights of 20, 70, dose-dependent manner, highlighting their potential
28, 55, and 57 kDa, respectively, have been found use in future applications (Herrera et al., 2010).
(Pessoa et al., 1998 and Kudo et al., 1997). These HGV infection is associated with prolonged survival
proteins perform the function of Protease, Helicase, in HIV-infected cohorts, and GBV-C E2 protein
and RNA-dependent RNA-polymerase. The inhibits HIV entry when added to CD4+ T cells
sequencing of the E1 and E2 regions has shown that (Xiang et al., 2012). This interaction induces a dose-
they are not hyper variable unlike the respective dependent release of RANTES and down-regulation
regions of HCV (Stapleton et al., 2004). Of interest of CCR5 surface expression with concomitant intra-
are the data obtained while studying the buoyant cellular accumulation of CCR5 proteins (Maidana et
density of HGV particles in a saccharose gradient al., 2005). Gómara et al. (2016) consider the use of
before and after treatment with the non-ionic non-pathogenic E1 HGV protein as an attractive
detergent Tween-80. These data suggest that there is source of peptides for the development of novel
a lipid envelope in the virus whose association with anti-HIV therapies. Haemolysis assay studies by
lipids reduces antibody formation. Galatola et al. (2015) demonstrated that E1 peptides
from HGV inhibit HIV-1 FP activity.
HGV virus receptor and HIV Infection
CD81 on T lymphocytes proteins have been reported Markers of HGV
as candidates for host cell entry. HGV envelope The basic marker used to diagnose HGV is RNA
protein E2 specifically binds to CD81 on T that is detectable by the amplification technique with
lymphocytes (Nattermann et al., 2003). Several but a preliminary stage of reverse transcription in which
not all studies have suggested that coinfection with cDNA is synthesized (reverse-transcriptase
HGV slows the progression of HIV disease and this polymerase chain reaction (RT-PCR)). Data on the

sequence of the RNA region coding for Helicase typified by an inverse correlation between anti-E2
(NS3) and the NS5A region are used to synthesize and viremia. The presence of serum viral RNA is
oligonucleotide primers. This choice is made due to also indicative of continuing infection so is that of
the high (83%-99%) stability of this region in E2 protein antibodies for clearance of viral particles
various viral isolates (the sensitivity was as high as from the patient’s body. It has been shown that the
200 copies/mL). Further investigations indicated production of HGV antibodies and the cessation of
that there might be false negative results in the viremia in most (60%-75%) immunocompetent
testing of some samples despite the fact that the patients occur spontaneously and they are followed
latter contained the virus. By taking this into by the generation of antibodies to the envelope
account, primers with the information coded in the protein E2 (Yang et al., 2006 and Thomas et al.,
5'-untranslated region (the sensitivity was as high as 1998). Two markers (RNA and anti-E2) of HGV
100 copies/mL) came into additional use for the have been concurrently detected in single studies (in
designing of diagnostic kits (Viazov et al., 1997). 5% of cases) (Novikov, 2000). The highest detection
The above primer kits had a high sensitivity, but rates of HGV antibodies are observed in individuals
also a rather high level of errors due to the aged above 50 years (Rey et al., 2000 and Wachtler
incomplete conservatism of respective viral RNA et al., 2000).
regions. An alternate primer kit for the region
coding for E2 has been developed. These primers Epidemiology of HGV
had 100% specificity for this RNA region; however, Infection with HGV is common worldwide
their sensitivity was not greater than 76.6%. Recent (Fallahian et al., 2010). Approximately 750 million
investigations propose the use of the two different people are actively infected (viraemic) and an
primer kits (for viral RNA NS3, NS5A, 5'UTR, or estimated 0.75–1.5 billion people have evidence of
E2 regions) for the accurate diagnosis of HGV RNA prior HGV infection (Chivero and Stapleton, 2015).
(Souza et al., 2006). HGV RNA has been detected Although HGV was discovered only 3 decades ago
in hepatocytes (Laras et al., 1999; Pessoa et al., (Leary et al., 1996 and Simons et al., 1995), several
1998 and Kudo et al., 1997), peripheral blood lines of evidence suggest that it is an ancient virus
lymphocytes and monocytes (Kao et al., 1999 and that is well-adapted to growth in the human host.
Zampino et al., 1999), vascular endothelial cells Genetically divergent isolates of HGV have been
(Handa and Brown, 2000), and other tissues (Tucker isolated from different parts of the world with
and Smuts, 2000). distribution extending to highly isolated populations,
such as indigenous tribes in Papua New Guinea and
HGV viremia may persist for a few years. The Central and South America (Simmonds and Smith,
infection is accompanied by the formation of 1999). The detection rate of HGV in the population
specific antibodies against the envelope protein E2 averages 1.7%. HGV, like other parenteral hepatitis
(anti-E2). These antibodies have a long survival and viruses, occurs universally, but non-uniformly. HGV
may prevent the body from reinfection. An enzyme is detectable in all ethnic groups. Analysis of the
immunoassay has been developed to detect serum results of examining 13, 610 blood donors described
GBV-C antibodies. The envelope E2 antigen in 30 reports revealed viral RNA in 649 (4.8%) of
(glycoprotein) was used as a viral antigen. Analysis cases. These included Caucasians (4.5%), Asians
of the sera from healthy individuals and patients (3.4%), and Africans (17.2%) (Wiwanitkit, 2005).
with hepatitis demonstrated that most anti- E2-
positive sera were HGV RNA negative, which The authors propose to test blood samples due to the
enabled anti-E2 to be regarded as a marker of high risk of infection with GBV-C (Dencs and
previous infection (Ilchenko et al., 2003; Loginov et Sebestyen, 2007 and Wiwanitkit, 2005). An
al., 2000; Novikov, 2000 and Hwang et al., 1999). investigation of the prevalence of HGV among
As a rule, HGV antibodies and RNA are not North-Eastern Thai blood donors carrying HBsAg
simultaneously encountered in a patient despite the and anti-HCV revealed the high frequency of HGV
fact that HCV, the nearest relation of HGV, is RNA (10% and 11%, respectively) in the co-

infected as compared with the controls (0%) is applied to detect HGV. In a study by Wiwanitkit
(Barusruk and Urwijitaroon, 2006). The (2005) it was shown that individuals who are HGV
development of an anti-E2 detection method has RNA positive may be at very high risk of B cell
promoted a complete definition of the prevalence of non-Hodgkin’s Lymphoma development.
HGV. E2 antibodies are several times more Khodavandi et al. (2011) proposed an association
frequently detectable than RNA in blood donors. between (HGV) viral hepatitis infections and non-
Hodgkin’s lymphoma. HGV might be considered as
Detection rate of anti-E2 in blood donors shows that a kind of "orphan" virus in search of a disease.
HGV is a parenterally transmitted infection (Yang et
al., 2006; Loginov et al., 2000 and Thomas et al., Immune Response to HGV
1998). The first verification of this fact was the HGV RNA is found in liver, spleen, bone marrow
experiments dealing with inoculation of primates and PBMCs, including T- and B-lymphocytes, NK-
with the blood of the Surgeon who fell ill in 1966 cells, and monocytes, although the mechanism of
(Linnen et al., 1996). Cases of acute post transfusion cell-to-cell transmission is unclear. HGV RNA is
hepatitis along with the enhanced activity of serum also present in serum microvesicles with properties
aminotransferases and the detection of blood HGV of exosomes. These microvesicles are able to
RNA in the absence of other markers of viral transmit viral RNA to PBMCs in vitro, resulting in
hepatitides has been documented (Rey et al., 2000; productive infection (Chivero and Stapleton, 2015).
Wachtler et al., 2000 and Balayan and Poleshchuk, HGV infection is associated with significantly lower
1998). Indirect evidence that HGB is parenterally expression of surface markers of activation on T-
transmitted lies in its more frequent detection in the cells (CD38, CD69 and CD25) in acutely HIV-
groups at higher risk for infection with hepatitis infected individuals (Maidana-Giret et al., 2009) and
viruses by similar routes of transmission, as well as chronically HIV-infected individuals compared with
the increased risk for infection in patients treated those without HGV, independent of HIV treatment
with multiple hemodialysis procedures and higher status (Bhattarai et al., 2012a; Stapleton et al.,
units of transfused blood products (Alter et al., 2012b). Proportion of naive CD8+ and CD4+ T-
1997; de Lamballerie et al., 1996 and Jarvis et al., cells is increased relative to memory and effector
1996). cells in individuals with persistent HGV infection
(Stapleton et al., 2012b). HGV is also associated
Pathogenesis of HGV with an increased number of double-negative (DN)
Hepatitis G virus enters the host primarily through T-cells (CD4- CD8- CD3+) (Bhattarai et al., 2012a).
blood and blood product (Jain et al., 1999). The DN T-cells are associated with reduced immune
virus was equally reported to be transmitted through activation and high levels of immune-suppressive
sexual intercourse and organ transplant (Samarbaf- cytokines, including TGF-β and IL-10, in HIV
Zadeh et al., 2015). The mechanism responsible for infection (Petitjean et al., 2012). Increased numbers
the development of hepatitis induced by GBV-C is of DN T-cells in HGV infection may play important
not clear today. Although this virus have been roles in reducing immune activation and
discovered in a patient with hepatitis and existing maintenance of immune homeostasis, contributing
case reports of acute and chronic hepatitis G, the to improved survival in HIV co-infection. The
hepatotropism remains controversial (Dias da Mota critical roles of T-cell escape mutations and
et al., 2013). In a study by Alhetheel and El-Hazmi impaired CD4+ T-cell help during HGV infection,
(2014) it was shown that HGV is capable of and how these features mediate viral persistence,
independent transmission, and neither HBV nor have not been elucidated yet.
HCV infection is a predisposing factor for HGV
infection or vice versa. The role of HGV in Antibodies against HGV structural proteins are
pathogenesis is not clear. Since this virus cannot be generally not detected during viremia and most
cultivated, molecular techniques such as Reverse individuals develop conformation-dependent
Transcription Polymerase Chain Reaction (RT-PCR) antibodies to E2 at or shortly following viral

clearance (Tanaka et al., 1998a). However, anti-E2 found to be HGV RNA positive. The more frequent
antibodies are occasionally found during active detection of markers of HGV in persons at increased
viremia and some of these individuals may be in the risk for sexually transmitted diseases is also indirect
act of clearing viremia (Schwarze-Zander et al., evidence for its sexual transmission. Wachtler et al.
2006). Report describes the detection of anti-HGV (2000) revealed HGV RNA in 27% and anti-E2 in
peptide antibodies (Fernandez et al., 2013). 35% of the HIV- infected, while in the control group
However, no clear relationship between peptide- these were 2% and 6%, respectively. The vertical
reactive antibodies in actively HGV-infected or transmission of HGV from infected mother to infant
convalescent subjects has been reported. Viral may now be considered proven (Lefrere et al., 2000;
infection of NK-cells is relatively uncommon, Ohto et al., 2000; Palombaet al., 1999 and Wejstal
although a few examples have been described. NK- et al., 1999). There may be intranatal infection of a
cells are permissive for vaccinia infection in vitro baby at delivery by the maternal passage, as
(Kirwan et al., 2006). In a study by Chivero et al. confirmed by the data on a significant reduction in
(2014) HGV RNA was found in highly purified NK the infection rates of neonates after cesarean section
cells obtained from four of five subjects (mean 42 of their mothers (Ohto et al., 2000). There is also
genome equivalents per 104 cells). Viral RNA was postnatal HGV infection. It was shown that on
shown to be taken up by NK-cells obtained from examining 288 mothers, 89% of the HGV- positive
donors not infected with HGV, and viral RNA babies have been infected 3 months after birth
increased and was released into culture supernatants (Lefrere et al., 2000). The level of viremia is a factor
by PBMCs in these studies (Chivero et al., 2014). that is of importance in the transmission of the virus.
As noted earlier, HGV RNA is present in serum By following up 24 babies born to mothers with a
extracellular microvesicles and these may be HGV RNA level of more than 10 copies/mL, Ohto
involved in infection of various PBMCs (Bhattarai et al.(2000) revealed HGV in 23 (96%) of them. The
et al., 2013). viremia index in the mothers whose babies proved to
be infected was significantly higher than that in
Detection Rate of HGV RNA in High Infection- those whose babies were seronegative. Most babies
Risk Groups had no clinical or biochemical signs of liver disease
The use of infected blood and its products promotes despite one-year HGV persistence (Halasz et al.,
the prevalence of HGV. In some countries such as 1999). Report by Wejstal et al. (1999) shows that
the USA, 18%-20% of all blood preparations are vertical transmission of HGV account for 75% -
infected with HGV, of them plasma being in 33%- 80% of cases and that of HCV is 2.8% - 4.2%.
84% (Jarvis et al., 1996) and in the United
Kingdom, 94%-100% of coagulation factor VIII-IX The frequent maternal- infant transmission of HGV
preparations are infected with this virus (Alter et al., may be the explanation for the high prevalence of
1997). the virus among the adult population at low risk of
parenteral and sexual transmissions. HGV was
This persistent infection is present in a considerable detectable in 9% and 28.6% of the children under 15
number of healthy blood donors and in more than years and above 16 years of age, which shows
35% of the human immunodeficiency virus (HIV)- detection of HGV increases with age (Mphahlele et
infected. There may be a sexual transmission in al., 1999).
hepatitis G, as in hepatitis B and C. This is
evidenced by the high detection rate of HGV RNA HGV Cellular Tropism
in homosexuals and prostitutes (13.4%-63.0%) HGV predominantly replicates in peripheral blood
(Stark et al., 1999 and Rubio et al., 1997) and mononuclear cells, mainly in B and T (CD4+ and
13.9%-24.8% (Sawayama et al., 1999 and Rubio et CD8+) lymphocytes and bone marrow (Xiang et al.,
al., 1997) respectively. Yeo et al. (2000) studied 2000; Handa and Brown, 2000; Kao et al., 1999 and
sexual transmission risk in 161 haemophilic patients, Zampino et al., 1999). The mechanism responsible
21% of the females in sexual contact with them were for the development of HGV-induced hepatitis is not

clear so far. Despite the described cases of acute and mechanisms that are responsible for persistent
chronic hepatitis G, its hepatotropicity remains infection are different from those for HCV.
controversial.
Thus, during 2-year follow-up, the average amino
Viral hepatotropicity is supported by the detection of acid sequence replacement in the E2-region was 100
HGV RNA in hepatocytes and by the development times lower in HGV than in HCV (Orii et al., 2000).
of acute and fulminant hepatitis following the Investigations indicated that viremia in HGV-
transfusion of infected blood and its products. Lang infected patients was low and equal to 10 -10
et al. (1998) reported interesting data on the copies/mL (Souza et al., 2006). It has been
immunohistochemical detection of HGV NS5 Ag in suggested that the viral particles that are present in
the liver biopsy specimens taken from patients with the blood use low- density lipoprotein receptors for
various liver diseases (Lang et al., 1998). Like penetration into the target cell and generate lipid
RNA- containing HCV, HGV does not integrate into complexes similar to those seen for HCV particles.
the genome of an infected cell, but it is located in its HGV may replicate in PBMC and interferon-
cytoplasm and the ―positive cells are diffusely resistant Daudi cells (Xiang et al., 2000).
arranged. The indirect evidence for the liver tissue Experiments were carried out to inoculate human
HGV replication is a considerable reduction in the PBMC lines and hepatocytes with RNA in vitro. The
serum content of viral RNA after liver same lines were infected with HCV as a control.
transplantation (Berg et al., 1999). In a third of These experiments demonstrated that HGV
serum-positive patients, RNA was undetectable in replicates only in CD4+ cells (Xiang et al., 2000 and
the hepatocytes despite the fact that tissue had been Fogeda et al., 1999). Studies of cells from different
repeatedly taken from different lobes of the liver organs of HGV-infected patients were conducted in
(Fan et al., 1999). A study of liver biopsy specimens parallel. They also detected traces of RNA- minus
from 12 GBV-C-positive patients revealed no RNA- strand virus. Thus, the in vitro and in vivo studies
minus strand responsible for replication and a RNA+ provide evidence that PBMC are the primary site of
plus strand only in half the patients with low titers, HGV replication. The contribution of not only the
which may be indicative of HGV contamination immune system, but also genetic predisposition to
from blood. prolonged viral circulation is suggested. HLA typing
in HGV- infected patients with haemophilia showed
After establishing that the hepatotropicity of HGV that 22% of the RNA-positive patients and 72% of
was low, the next stage of elucidating the the anti- E2-positive patients had HLA DQ7, HLA
pathogenicity of the virus was to study its tropism to DR15 and HLA DR8. There is also evidence for low
other tissues. Handa et al. (2000) determined the content of CD4+ and the high level of CD8+
presence of RNA- minus strand in the vascular lymphocytes in anti-E2-positive patients, which
endotheliocytes (Handa and Brown, 2000). In the makes it possible to predict GBV-C clearance
authors’ opinion, isolation of HGV RNA from a (Toyoda et al., 2000). HGV replication in peripheral
liver biopsy specimen may reflect viral replication in blood monocytes and lymphocytes, and the spleen
the endothelium of the vessels located in the liver and bone marrow, combined with long viral
(Handa and Brown, 2000). Tucker et al. (2000) persistence suggest that HGV replicates
reported the detection of RNA+ plus strands in all 23 predominantly in the haematopoietic system. Arican
study organs taken for analysis from HGV-infected et al. (2000) on examining 44 patients with non-
patients who had suddenly died (Tucker and Smuts, Hodgkin’s lymphoma, revealed markers of HCV
2000). However, both RNA strands were found only infection in 5% of cases but none of them was found
in the spleen and bone marrow. The comparison of to have HGV RNA.
nucleotide sequences in the E2- region and the lack
of occurrence of mutant viral forms during antiviral However, meta-analysis of 178 cases of non-
therapy with interferons suggested that the Hodgkin’s lymphoma and 355 healthy volunteers
indicated HGV RNA in 8.4% (15/176) and 0.8%

(3/355) of the examinees, respectively, which points The alanine aminotransferase (ALT) activity in
to the high risk of HGV in patients with lymphoma HGV unlike HCV does not correspond to the degree
(Wiwanitkit, 2005). There is evidence for the of viremia and the severity of hepatic histological
frequent detection of HGV RNA in patients with changes. By examining 1075 patients with isolated
leukemia as compared to those with hyper -transaminasemia for 6 months. Berasain et al.
myeloproliferative diseases (Pavlova et al., 1999). (2000) revealed HGV RNA in 74 (6.9%) patients.
Crespo et al. (1999) reported the development of Only one (0.09%) patient was monoinfected. There
aplastic anaemia in a 24-year-old male patient with is also evidence for two-fold increases in the activity
acute hepatitis G (Crespo et al., 1999). Frequent of alkaline phosphatase (AP) and γ-
transfusions in these patients may be one of the glutamyltranspeptidase (γ-GTP) in HGV positive
causes of HGV infection. There are higher detection patients (Colombatto et al., 1996). Study in Japan
rates of HGV RNA (11%) and anti-E2 (17%) in reported GBV-C RNA in three of six patients with
autoimmune hepatitis than in the control group (2%) acute fulminant hepatitis of uncertain etiology
(Tribi et al., 1999). Heringlake et al. (1996) revealed (Yoshiba et al., 1995).
serum GBV-C RNA in 6.7%, 10.0% and 12.5% in
patients with types I, II and III autoimmune Fibrosis of the portal tract without lymphoid-cell
hepatitis, respectively (Heringlake et al., 1996). infiltration (Suiz et al., 1997), steatosis and
HGV is typified by a long-term (as long as 16 years) insignificant inflammatory infiltration of the portal
persistence in human blood (Kao et al., 1997). tract (Fattovich et al., 1997; Vargas et al., 1997;
Loginov et al., 1999) were detectable in isolated
Clinical Manifestations and Histological Finding persistent HGV infection. The histological activity
of HGV Infected Patients index in patients infected with HGV alone was
The clinical picture of HGV infection is commonly observed to be much lower than that in patients with
similar to that of the subclinical and anicteric types HCV+HGV or HCV (Guilera et al., 1998;
of hepatitis with normal or low aminotransferase Sharafanova et al., 2001 Ilchenko and Karlovich,
activities (Alter, 1996). The incubation period of the 2007). In HGV monoinfected patients, moderate or
virus after transfusion seems to be 14-20 days, and if mild focal portal hepatitis was prevalent with slight
hepatitis occurs, the illness is typically mild periportal infiltration and lobular components being
(Zetterman, 1999). Report shows evidence of HGV found in single cases. The bile tract displayed
involvement in the development of aplastic anaemia epithelial fragmentary swelling and flattening and
(Riaz Shah et al., 2011). HGV-associated hepatitis no nuclei in some epitheliocytes. Some bile ducts
runs with normal biochemical parameters in 75% of demonstrated partially desquamated epithelium in
patients (Arican et al., 2000). There are reports on the case of higher activities (Ilchenko et al., 2002;
the occurrence of acute and chronic (mild and Ilchenko and Karlovich, 2007). Intra operative
moderate) (Souza et al., 2006; Il’chenko et al., biopsies from HGV positive patients with
2002; Rey et al., 2000 and Di Bisceglie, 1996) cholelithiasis who were monoinfected with HGV,
hepatitis and hepatic fibrosis (Ilchenko et al., 2003 indicated that they had mild chronic hepatitis and, in
and Kao et al., 1997). The incubation period of some cases, viral RNA in the liver tissue and
acute viral hepatitis G averages 14-20 days. The gallbladder mucosa. It is suggested that HGV may
outcome of acute hepatitis may be: Recovery with play a role in the production of lithogenic bile and in
the disappearance of serum HGV RNA and the the development of cholelithiasis (Chekmazov et al.,
emergence of anti-E2; Development of chronic 2005). Co -infection of HGV with hepatitis B, C,
hepatitis (CH) with serum HGV RNA being and D viruses is significantly more frequently
persistently detectable and Presence of HGV RNA detected than monoinfection (Kumar et al., 2007).
without biochemical or histological signs of liver No differences were found in the clinical
disease. manifestations (including those in the chronic
pattern and outcome) of the disease, biochemical
parameters, or the severity of hepatic histological

changes in patients with HBV and/or HCV as low RNA titer (mean, 3.3 × 10 copies/mL) more
compared in those with HBV+HGV and/or HCV frequently responded to the therapy than those who
+HGV (Kao et al., 1997; Fabris et al., 1998; had a higher one (mean, 3.5 × 10 copies/mL)
Bychenko et al., 2003). By examining 420 patients, (Enomoto et al., 1998 and Kao et al., 1997).
Tanaka et al. (1998) revealed a higher ALT activity
in the group of patients coinfected with HCV and There is now a prevailing opinion that HGV has no
HGV than in those infected with HCV. By impact on the efficiency of α-interferon treatment
comparing histological changes in the liver tissue of for chronic hepatitis C (Garcia et al., 2000 and Orito
patients with HCV and HCV + HGV, Moriyama et et al., 1997). At the same time some investigations
al. (2000) detected more significant bile duct suggest that the therapy causes more frequent
damages, perivenular and pericellular fibrosis in the adverse reactions in patients with HCV+HGV and
latter group of which 28 (9%) patients were found to that after its termination, this group of patients has a
have RNA for HCV and HGV. Complaints and higher histological activity index (Pramoolsinsap et
clinical symptoms did not differ in the groups of al., 1999 and Szaflarska-Szczepanik et al., 1999).
patients with HCV and HCV+HGV. There was no
evidence for the impact of HGV on the clinical Diagnosis
manifestations and the course of concomitant HCV High prevalence rates of HGV have been reported
infection. among selected risk groups including intravenous
However, analysis of liver tissue morphological drug users, multiply transfused patients,
changes in patients coinfected with HCV and HGV haemodialysis patients, haemophiliacs and
revealed slightly more frequent epithelial damage in individuals receiving pooled plasma or intravenous
the bile duct (89%) than in those infected with HCV immunoglobulin. HGV cannot be cultivated in tissue
(67%), which manifested itself as lysis of the cell cultures or any other normal methods used for
epitheliocytic nuclei, as well as flattening, virus cultivation. Diagnosis of HGV depends on
destruction, and swelling of the epithelium and its two methods; acute infection can be diagnosed by
lymphocytic infiltration. Whether HGV influences detection of HGV RNA by PCR, while past
the course of CHC and whether therapy with infection can be diagnosed by detection of antibody
interferon is effective are currently being discussed. to E2 protein of the virus by ELISA (Chen et al.,
Most studies demonstrate no differences in the 1999). However, anti E2 antibodies to HGV and
clinical course of the disease, biochemical HGV RNA are almost mutually exclusive. It has
parameters, or the magnitude of hepatic histological been reported that 60%-70% patients develop
changes in both HCV alone and in combination with antibodies after infection. As such, the detection of
HGV (Slimane et al., 2000; Quintero et al., 2000 HGV RNA and anti-E2 is necessary to accurately
and Enomoto et al., 1998). A study for the therapy define the prevalence of HGV infection in a
of HGV is based on the evaluation of interferon population (Siddiqua et al., 2010).
treatment in patients coinfected with HCV+HGV.
HGV was ascertained to be sensitive to interferon. Treatment and Prevention
Administration of α-interferon (α-IFN) to patients at There is no specific treatment for the hepatitis G
a dose of 3 000 000 IU thrice weekly for 6 months virus. IFN treatment was reported to be active
resulted in ALT activity normalization and serum against HGV infection (Baba et al., 1997).
HGV RNA clearance in 18%-40% of the patients Interferon alpha is combined quite often with
treated with α-IFN (Fujisawa et al., 2000 and ribavirin quicker to reach positive result.
McHutchison et al., 1997). Six months after Maintaining a nutritious diet, avoiding alcohol, and
termination of a course of therapy, there were getting adequate rest are advised. Since hepatitis G
persistent biochemical and virological responses in is a blood borne infection, prevention relies on
55%-57% of patients (Garcia et al., 2000). The avoiding any possible contact with contaminated
therapeutic efficiency was observed to depend on blood. Drug users should not share needles,
baseline HGV RNA levels. The patients who had a syringes, or other equipment.

Conclusion Baba, T., Makino, R., Shibata, M., Harada, E.

It remains unclear what disease state HGV infection and Mitamura, K. (1997). Interferon treatment for
causes acutely and in the long-term. Despite reports hepatitis G virus infection in patients with chronic
shows that HIV / HGV coinfected individuals have hepatitis C. Nihon Rinsho; 55(3):625-30.
higher CD4+ lymphocyte counts and better AIDS- Balayan, M. S. and Poleshchuk, V. F. (1998). Viral
free survival rates, caution and vigilance must be hepatitis in primates: experimental reproduction
maintained, there is a growing consensus that HGV and natural infection. Virusnyehepatity (Viral
is "an orphan virus looking for a disease". However, hepatitides); 3:3–12.
Barusruk, S. and Urwijitaroon, Y. (2006). High
the role of HGV in fulminant hepatitis is an
prevalence of HGV coinfection with HBV or
unresolved question. The threat that HGV may pose
HCV among northeastern Thai blood donors.
to the Global blood supply is an important issue.
Southeast Asian Journal of Tropical Medicine;
37:289–293.
Acknowledgements Bassit, L., Kleter, B., Ribeiro-dos-Santos, G.,
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that we could not lay our hand and cite here. of Sao Paulo, Brazil. Vox Sang; 74:83–87.
Berasain, C., Betes, M., Panizo, A., Ruiz, J., Herrero,
Conflict of Interests J. I., Civeira, M. P and Prieto, J. (2000).
The authors declare that there is no conflict of Pathological and virological findings in patients
interests regarding the publication of this article. with persistent hypertransaminasaemia of
unknown aetiology. Gut; 47:429–435.
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Original Research
SJMLS-2(1)-2017-004
Cardiovascular Risk Factors in South-Western Nigeria: A WHO Step-
Wise Approach
Saheed Opeyemi Usman* 1, Olabisi Oyepero Kalejaye 2, Ibiwumi Nafisat Usman 3, Adebayo Suleiman 4,
Ndumiso Tshuma 5, Adewale Kayode Ojogbede 6, Olusola John Fatunmbi 7, Gbemiga Peter Olubayo 8,
Sogo Odesanmi 9, Jessica Yun
Department of Chemical Pathology, Faculty of Medicine, Nnamdi Azikiwe University, Nnewi, Nigeria 1,
Health System Strengthening Unit, Catholic Relief Services, Akure, Nigeria 2, Department of Community
Medicine, Ladoke Akintola University of Technology, Osogbo, Nigeria 3, Department of Strategic
Information, Institute of Human Virology Nigeria, Lagos, Nigeria 4, Community AIDS Response,
Johannesburg, South Africa 5, Department of Strategic Knowledge Management, Equitable Health Access
Initiative, Akure, Nigeria 6, Department of Laboratory Services, Union Diagnostics, Osogbo, Nigeria 7,
Department of Community Medicine, Equitable Health Access Initiative, Akure, Nigeria 8, Federal College of
Education, Osiele, Abeokuta, Nigeria 9, Community AIDS Response, Johannesburg, South Africa 10.
Corresponding Author*: Senatorhopsy@yahoo.com/+234-803-467-6223
Abstract engage in any form of physical exercise. There is an

Smoking, physical inactivity, alcohol consumption, unacceptable prevalence of controllable risk factors
as well as, poor diet such as high sugar for cardiovascular diseases due to poor health-
consumption, which are unhealthy lifestyles, all seeking behaviors and unhealthy lifestyle leading to
constitute major risk factors for cardiovascular poor health outcomes thus prompting the urgent
diseases, some of which can be controlled, treated need for sensitization & health promotion
or modified. This study was carried out to determine programmes on prevention and control measures,
the prevalence of hypertension and obesity with the as well as an implementable national policy, to
cardiovascular risk factors that Africans are largely combat and stem the trend of these disorders in
exposed to, with a view to making necessary order to enhance life expectancy.
recommendations that would help improve them.
This cross-sectional study was carried out in South- Keywords: Cardiovascular, Risk, Nigeria, Alcohol,
Western Nigeria. The target population were adults WHO, Step-Wise Approach
who are 30 years old or above. A multi-stage
sampling technique was used to select the Introduction
respondents. All data were statistically analyzed,
The majority of cardiovascular diseases (CVD) are
using statistical package for the social sciences
caused by risk factors that can be controlled, treated
(SPSS) and statistical test of significance was
performed with Chi-Square test. A total of 438
or modified, such as high blood pressure,
consenting respondents participated in the study cholesterol, overweight/obesity, tobacco use, lack of
with a mean age ± SD of 39.74 ± 21.24 years. physical activity and diabetes. However, there are
Among the subjects, 3.9% of the respondents were also some major CVD risk factors that cannot be
currently smoking at least one cigarette per day, controlled. In terms of attributable deaths, the
24.9% currently consume alcoholic drink, 19.6% leading CVD risk factor is raised blood pressure (to
consume snacks daily and a massive 70.5% don’t which 13 per cent of global deaths is attributed),

followed by tobacco use (9 per cent), raised blood hypertension among lecturers was 21.33%, with
glucose (6 per cent), physical inactivity (6 per cent) 17.33% reported to be of normal weight, 60.00%
and overweight and obesity (5 per cent). Modifiable were overweight, 22.67% being obese while 2.67%
risk factors include high blood pressure currently smoke (Ordinioha, 2013). The prevalence
(hypertension), tobacco use, raised blood glucose of overweight, obesity and hypertension were
(diabetes), physical inactivity, unhealthy diet, 25.3%, 26.7% and 16.0% respectively as reported
cholesterol or lipids, overweight and obesity. The among traders in Ijebu Ode (Oladoyinbo et al.,
non-modifiable risk factors include age, gender and 2015), while prevalence of overweight, obesity and
family history (Mendis et al., 2011). All countries, hypertension were 39.9%, 12.3% and 34.8% among
irrespective of their stage of economic development urban market traders in Lagos. A massive 92% was
or demographic and epidemiological transition reported to be physically inactive, 0.3% of the
generally face the burden of non-communicable females’ smoke cigarette while 17.5% of the male
diseases (NCD). The prevalence of NCDs is rising traders’ smoke cigarette (Odugbemi et al., 2012). In
rapidly in Africa and is projected to cause almost Tehran, risk factors in an Iranian urban population
three-quarters as many deaths as communicable, showed that the prevalence hypertension, obesity
maternal, perinatal and nutritional diseases by 2020, and smoking were 20.4%, 14.4% and 22.3%
and to exceed them as the most common causes of respectively (Azizi et al., 2002). The prevalence of
death by 2030 (WHO, 2008). About 80% of the hypertension in Lome, Togo, was reported in a 2012
burden of NCDs is already occurring in middle- and research work to be 26.6%. Sedentary lifestyle was
low-income countries such as Nigeria (WHO, 2015 reported to be 41% while smoking and alcohol use
and Yarahmadi et al., 2013). The outcome of a 2015 were said to be 9.3% and 11% respectively (Baragou
research work on the prevalence of physical et al., 2012).
inactivity, hypertension, obesity and tobacco
smoking in Maiduguri Nigeria, revealed that 15.3%, Statement of Problem/Rationale of Study
4.6%, 19.2% and 13.1% were hypertensive, obese, The majority of cardiovascular diseases (CVD) are
physically inactive and tobacco smokers caused by risk factors that can be controlled, treated
respectively, as significant differences were found or modified, such as high blood pressure,
between the prevalence of obesity, age and marital cholesterol, overweight/obesity, tobacco use, lack of
status while prevalence of physical inactivity was physical activity and diabetes. However, there are
found to be significantly higher among females than also some major CVD risk factors that cannot be
males, but, smoking prevalence was significantly controlled. Therefore, surveillance of Non-
higher among males than females (Aliyu et al., Communicable Disease (NCD) risk factors should
2015). The authors of a 2014 research work on include social determinants of cardiovascular health,
dietary pattern, lifestyle, nutrition status and especially as the understanding of the individual and
prevalence of hypertension among traders, reported social determinants of cardiovascular health
that 50.7% of the participants eat their largest meal behaviours is among the top 20 priority areas for
at dinner, 49.9% eat snacks every day, 66.7% eat NCD research in Low & Middle Income Countries
fatty foods, 27.1% and 33.0% drink fruit juice and (LMICs).
carbonated drinks respectively thrice weekly or
more, 6.0% and 58.8% eat fruits and vegetables, Aim and Objectives of the Study
respectively less than thrice a week or not at all, The aim of the study was to identify the
50.7% live a sedentary lifestyle, 5.2% currently cardiovascular risk factors in South-Western Nigeria
smoke cigarette and 10.8% had consumed alcohol using the WHO Step-wise approach to determine the
within the past 30 days while the prevalence of dietary pattern, nutrition status, lifestyle, as well as
overweight , obesity and hypertension were said to the prevalence of high blood pressure and obesity.
be 28.9%, 28.1% and 29.1% respectively (Awosan The specific objectives included; To determine the
et al., 2013). In 2013, modifiable risk factors of prevalence of hypertension & obesity, evaluate the
hypertension studied, showed that the prevalence of awareness of cardiovascular diseases and to

determine the cardiovascular risk factors Nigerians centimetres (cm) were measured using a flexible
are largely exposed to. non-stretchable tape measure and subsequently used
to calculate the Waist-Hip Ratio (WHR) (WHO,
Research Hypothesis 2008). Blood pressure was measured in a sitting
1) Educational status has no significant position using a mercury sphygmomanometer with
influence on the risk factors for the appropriate size of cuff; and standard measures
cardiovascular diseases will be taken to ensure accuracy. Two consecutive
2) Income has no significant effecton the risk measurements were taken at an interval of at least
factors for cardiovascular diseases three minutes, with the mean calculated for each
subject.
Materials and Methods
This cross- sectional study was carried out in towns Sample Size
across the three senatorial districts of each of the six Sample size calculation was done using 95%
South-Western States in Nigeria. The target confidence interval, 0.05 precision and prevalence
population were adults who are 30 years old or rate. The report of the 2013 study revealed a 22.2%
above in these districts. Ethical approval with prevalence of obesity among Adult Nigerians [15].
protocol number ERC/2016/08/21/38B was obtained Using Leslie Fischer’s formula for population
from the research and ethics committee of the >10,000, the formula for sample size calculation is:
Federal Teaching Hospital, Ado Ekiti, Nigeria. A n = Z2PQ/d2 (Alexander et al., 2013).
semi-structured questionnaire was administered n = Z2PQ/d2
consecutively to 438 respondents. Demographic and Where:
socio-economic information obtained were included. n = minimum sample size, d = degree of precision
Data was collected using a modified(taken form asof0.05),
the
WHO Step-wise instrument for chronic disease risk Z = standard normal deviation at 95% confidence
factor surveillance that consist of the questionnaire interval which is 1.96,
component, behavioural measurements and physical P = proportion of the target population (estimated at
parameters (Bonita et al., 2013). 22.2% which is 22.2/100 = 0.222),
Q = alternate proportion (1-P) which is 1-0.222=
A multi-stage sampling technique was 0.778used to select
the respondents from selected local government n = (1.96)2 (0.222) (0.778) = 265
areas (LGAs) in each of the three senatorial districts (0.05)2
in each of the six States in Western Nigeria. In stage Also, adding a 5% non-response rate, the minimum
1 from a sampling frame of the entire number of sample size (n) will be 5/100 X 265 = 13.25
local government areas in each senatorial districts of Thus, it will be 13.25 + 265 = 278.25 = 278 = n
each state, one-third number of LGAs was selected
using simple random sampling method. In stage 2, a Statistical Analysis
list of towns in each of the selected LGA’s was Data was statistically analysed using Statistical
randomly made. In stage 3, houses in the towns were Package for the Social Sciences (SPSS) for windows
randomly selected. The final stage involved in the version 20.0 software (SPSS Inc., Chicago, IL,
selection of consenting adults who are 30 years old USA). All data were expressed as Mean ± Standard
and above. The questionnaires were then Deviation (SD). Frequency counts were generated
administered on the respondents. for all variables and statistical test of significance
Body Mass Index (BMI) was calculated as weight was performed with Chi-Square test. Significance
(kg) divided by height2 (m2) and used as a marker was fixed p <0.05 and highly significance is p <
for nutritional status to classify subjects according to 0.01.
World Health Organization (WHO) guidelines
(Tsigos et al., 2008). Waist Circumference (WC) in
centimetres (cm) and Hip Circumference (HC) in

Results drinks are consumed daily by 71 (16.2%), weekly by

Socio-Demographic Data 124 (24.4%) and occasionally by 195 (44.5%)
A total of 438 consenting respondents participated in respondents. A massive three hundred and nine
the study. Most of the respondents were in the age (70.5%) respondents don’t engage in any form of
range of 26 – 35 years, 154 (35.2%) followed by 36 physical exercise.
– 45 years, 128 (29.2%), with a mean age ± SD of
39.74 ± 21.24 years. Most of the respondents were In table 2, 21.7% of the respondents consume fruits
married, 300 (68.5%), Christians, 314 (71.7%) and once in a while, as the regularly consumed fruits
had first degree, 123 (28.1%) while trading/business include apple, orange, banana, pineapple,
is the major vocation, 143 (32.6%) among the watermelon and pawpaw. One hundred and thirty-
respondents. Table I shows the socio-demographic eight (31.5%) reportedly make fruit a complete meal
data of respondents. occasionally. Vegetables regularly consumed such
as cabbage, cucumber, pumpkin, carrot, bitter leaf,
Thirty-two (7.3%) of the respondents have smoked spinach and lettuce. Vegetables are eaten at interval
cigarette while seventeen (3.9%) are currently mostly every three days as reported by 21.9% of the
smoking at least one cigarette per day. Of the respondents. Most of the respondents, 208 (47.5%)
respondents, 201 (45.9%) have consumed alcoholic often sleep between 6 to 8 hours every night while
drink at one time or the other, with a 3.2% 70 (16.0%) and 37 (8.4%) reported that at least one
respondents’ first consumption being before the age of their parents suffered diabetes mellitus and
of 18 years. Moreover, 109 (24.9%) currently hypertension respectively.
consume alcoholic drink including beer, wine and
gin, especially taking at least one bottle of beer or Table 3 shows the physical measurements. Result
sachet of gin. Full day meals (breakfast, lunch and indicated that 27.6% respondents were overweight,
dinner) taken in the previous three days by 28.5% had a pre-hypertension figure for systolic
respondents showed that they were mainly blood pressure and 18.3% had a pre-hypertension
comprised of carbohydrates, proteins, minerals salt figure for diastolic blood pressure.
and fat & oil, with lesser presence of vitamins, fruits
and vegetables, as two hundred and twenty-three Table 4 shows Chi square result presenting the
(50.9%) of them consume no meal after 9pm in the influence of educational status and income on
evening. 201 (45.9%) respondents eat snacks such as cardiovascular diseases risk factors.
sandwich, meat or fish pie, chips, doughnuts,
biscuits and ice cream occasionally while 86
(19.6%) consume snacks daily. Carbonated soft

Table I – Socio-demographic data of Respondents

Variables Frequency (%)
Age Group (years)

< 25 42(9.6)
26 – 35 154 (35.2)
36 – 45 128 (29.2)
46 – 55 65 (14.8)
56 – 65 26 (5.9)
> 65 23 (5.3)
Marital Status
Single 102 (23.3)
Married 300 (68.5)
Separated 12 (2.7)
Divorced 5 (1.1)
Widowed 19 (4.3)
Religion
Christianity 314 (71.7)
Islam 124 (28.3)
Highest level of education
No formal education 27 (6.2)
Primary 50 (11.4)
Secondary 113 (25.8)
Diploma 83 (18.9)
Degree 123 (28.1)
Masters 31 (7.1)
Doctoral 11 (2.5)
Occupation
Artisan 87(6.2)
Trading/Business 143(32.6)
Public Servant 86 (19.6)
Private Sector Worker 78 (17.8)
Teaching 25 (5.7)
Unemployed 19 (9.1)
Monthly Income (Naira)
Less than #5,000 31 (7.1)
#5,000 – #18,000 72 (16.4)
#18,001 – #30,000 69 (15.8)
#30,001 – #50,000 85 (19.4)
#50,001 – #100,000 107 (24.4)
#100,001 – #150,000 25 (5.7)
#150,001 – #200,000 19 (4.3)
#200,001 – #300,000 15 (3.4)
#Greater than 300,000 15 (3.4)

Table 2 – Behavioural Measurements of Respondents

Fruit eating frequency

Everyday 75 (17.1)
Every two days 57 (13.0)
Every three days 81 (18.5)
Weekly 73 (16.7)
Once in a while 95 (21.7)
No specific time 32 (7.3)
No response 25 (5.7)
Fruit taken as complete meal occasionally
Yes 138 (31.5)
No 290 (66.2)
Vegetable eating frequency
Everyday 82 (18.7)
Every two days 95 (21.7)
Every three days 96 (21.9)
Weekly 64 (14.6)
Once in a while 68 (15.5)
No specific time 8 (1.8)
Vegetable taken as complete meal occasionally
Yes 117 (26.7)
No 309 (70.5)
Number of times individual eat per day
Twice 147 (33.6)
Thrice 224 (51.1)
Four times 39 (8.9)
Means of transportation to work place or workshop
Motorcycle 137 (31.3)
Vehicle 147 (33.6)
Bicycle 6 (1.4)
Trek 86 (19.6)
Hours of night sleep per day
<2hours 3 (0.7)
2 – 4 hours 30 (6.8)
4 – 6 hours 131 (29.9)
6 – 8 hours 208 (47.5)
>8 hours 50 (11.4)
Parent suffered diabetes or hypertension
Diabetes mellitus 70 (16.0)
Hypertension 37 (8.4)
None 282 (64.4)

Table 3 – Physical parameters of Respondents

Body Mass Index (BMI) (kg/m2)

< 18.5 (Underweight) 18 (4.1)
18.5 – 24.9 (Normal Weight) 222 (50.7)
25.0 – 29.9 (Overweight) 121 (27.6)
30.0 – 34.9 (Class I Obesity) 54 (12.3)
35.0 – 39.9 (Class II Obesity) 17 (3.9)
≥ 40.0 (Class III Obesity) 6 (1.4)
Average Systolic Blood Pressure (SBP) (mmHg)
<90 (Hypotension) 5 (1.1)
90 – 119 (Desired) 265 (60.5)
120 – 139 (Pre-hypertension) 125 (28.5)
140 – 159 (Stage I Hypertension) 26 (5.9)
160 – 179 (Stage II Hypertension) 15 (3.4)
≥ 180(Hypertensive Urgency) 2 (0.5)
Average Diastolic Blood Pressure (DBP) (mmHg)
<60 (Hypotension) 10 (2.3)
60 – 79 (Desired) 304 (69.4)
80 – 89 (Pre-hypertension) 80 (18.3)
90 – 99 (Stage I Hypertension) 33 (7.5)
100 – 109 (Stage II Hypertension) 6 (1.4)
≥ 110 (Hypertensive Urgency) 8 (1.8)
Waist-Hip Ratio (WHR)
< 0.80 (female)/< 0.90 (male) (Normal Weight) 303 (69.2)
0.80 – 0.84 (female)/0.90 – 0.99 (male) (Overweight) 79 (18.0)
> 0.85 (female)/ > 1.00 (male) (Obesity) 56 (12.8)
Table 4 – Chi square result showing influence of Educational status and Income on cardiovascular
diseases risk factors
VARIABLES χ² df Critical value Decision
Educational status influence on 6.71 14 23.29 Accepted
risk factors (alcohol, tobacco)
Educational status influence on 28.37 14 23.29 Rejected

risk factors (fruits & vegetables)
Influence of income on 8.25 18 28.87 Accepted
risk factors (alcohol, tobacco)
Influence of income on 16.51 18 28.87 Accepted

risk factors (fruits & vegetables)

Discussion Eastern Nigeria (Aliyu et al., 2015); 28.1% reported

A high prevalence of unhealthy eating and lifestyle in North-western Nigeria (Awosan et al., 2013);
habits were observed among participants in this 22.67 in South-South Nigeria (Ordinioha, 2013), as
study, especially as majority eat fruit once in a well as 14.4% reported in Tehran Iran [10] while the
while, vegetables consumed mostly on the average prevalence of hypertension in this study is lower in
of every three days, 3.9% currently smoking at least comparison with other studies, with 26.6% reported
one cigarette per day, 24.9% currently consuming in Lome Togo (Baragou et al., 2012), 20.4%
alcoholic drinks, 19.6% consume snacks such as reported in Tehran (Azizi et al., 2002), 16.0% and
sandwich, meat or fish pie, chips, doughnuts, 34.8% reported in some parts of Western Nigeria
biscuits and ice cream on a daily basis, 16.2% respectively (Oladoyinbo et al., 2015 and Odugbemi
consume carbonated soft drinks, driving reported as et al., 2012) while it is higher than the prevalence of
the main mean of transportation to work place or 4.6% reported in North Eastern Nigeria. Although
workshop enhancing sedentary lifestyle, with a the prevalence reported in this research work largely
massive 70.5% reportedly not engaging in any form appears lower in comparison with others, they are
of physical exercise. This finding is consistent with still not low enough for a good society and this can
the outcome of the 2014 research on dietary pattern, be attributed probably to general inadequate
lifestyle and nutritional status which showed that participation in physical activities facilitating
49.9% eat snacks every day, 33.0% drink carbonated sedentary behaviour coupled with poor feeding habit
drinks thrice weekly or more, 6.0% and 58.8% eat and family lifestyle.
fruits and vegetables, respectively less than thrice a
week or not at all, 50.7% live a sedentary lifestyle, The acceptance of the hypotheses on educational
5.2% currently smoke cigarette and 10.8% had status and income influence on the risk factors for
consumed alcohol within the past 30 days (Awosan cardiovascular diseases, shows that regular habits
et al., 2013).The high prevalence of consumption of that predispose a typical individual to cardiovascular
high energy dense foods and drinks, smoking habits diseases such as tobacco smoking including
and alcoholism among the participants in this study cigarettes, consumption of alcoholic drinks
is of tremendous concern, considering the fact that including beer, wine, spirits, etcetera, are not
these factors together predispose an individual to necessarily determined by the educational level or
various cardiovascular and metabolic diseases average income of the individuals, as it is only
especially with age advancement. habitual and characteristic of them. Also, the
acceptance of the hypothesis on the influence of
Findings from this research showed that 12.3% of income on fruits and vegetables consumption, shows
the participants had their body mass index (BMI) that cost of these fruits commonly consumed
between 30.0 and 34.9 kg/m2 which is classified as including apple, orange, banana, watermelon,
Class I Obesity, 27.6% overweight participants with pawpaw, among others as well as vegetables such as
BMI of 25.0 – 29.9 kg/m2, 5.9% had their average bitter leaf, cucumber, cabbage, lettuce and spinach,
systolic blood pressure (SBP) after consecutive is not a major determinant regarding their
readings between 140 and 159 mmHg equivalent to consumption as they are believed to be within
stage I hypertension, 7.5% had their average affordable rates. However, the rejection of the
diastolic blood pressure (DBP) after consecutive hypothesis on the influence of educational status on
readings between 90 and 99 mmHg equivalent to the consumption of the various fruits and vegetables
stage I hypertension and 12.8% had their waist-hip shows that the level of education and disposition to
ratio (WHR) within the obesity range with females > information of an individual determines his or her
0.85 and males > 1.00 (Eckel et al., 2014; WHO, decision on the consumption including frequency,
2008 and WHO, 2006). The prevalence of obesity even as regards to how regularly they are taken, in
reported in this study was found to be lower as order to presumably attain better health and lower
compared to other findings around the country and the risk of cardiovascular diseases.
world, as 19.2% prevalence was reported in North-

Conclusion and Recommendation non-communicable diseases: A stepwise

There is an unacceptable prevalence of controllable approach. The Lancet; 381(9866): 575–584.
risk factors for cardiovascular diseases due to poor Chukwuonye, I.I. Chuku, A., John, C., et al. (2013).
health-seeking behaviours and unhealthy lifestyle Prevalence of overweight and obesity in adult
leading to poor health outcomes thus prompting the Nigerians - A systematic review. Diabetes,
urgent need for sensitization & health promotion Metabolic Syndrome and Obesity: Targets and
programmes on prevention and control measures Therapy; 6:43–47.
focusing mainly on smoking cessation, increasing Eckel, R.H., Jakicic, J.M., Ard, J.D., et al. (2014).
physical activity, balanced/healthy diet and 2013 AHA/ACC guideline on lifestyle
alcoholism issues, as well as an implementable management to reduce cardiovascular risk: A
national policy, to combat and stem the trend of report of the American College of
these disorders in order to boost better health Cardiology/American Heart Association task
outcomes and enhance life expectancy in this part of force on practice guidelines.
the world. Circulation;129(25): S76-99.
Mendis, S., Puska, P. and Norrving, B. (2011).
Conflict of Interest Declaration Global Atlas on Cardiovascular Disease
No conflict of interest. prevention and control:2-13.
Odugbemi, T.O., Onajole, A.T. and Osibogun, A.O.
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non-communicable risk factors in the capital


Original Research
SJMLS-2(1)-2017-005
A Review on the Epidemiology and Burden of Neglected Tropical
Diseases.
Galalain S.M.1, Bandiya H.M.1, Galalain A.M.2 and Mohammed Y*.3
Department of Biological Sciences, Faculty of Science, Usmanu Danfodiyo University, Sokoto 1,
Department of Plant Biology, Faculty of Science, Bayero University Kano 2, Department of Medical
Microbiology, Faculty of Basic Medical Science, College of Health Sciences, Usmanu Danfodiyo
University, Sokoto 3.
Author for Correspondence*: yahyakt@yahoo.com/+234-803-686-7478
Abstract (Bilhazia), Soil Transmitted Helminths,

Neglected Tropical Diseases are group of infectious Echinococcosis, Cysticercosis / Taeniasis,
diseases caused by various microorganisms that Fascioliasis, Dengue virus and Rabies virus.
cause debilitating infections with worrisome Neglected topical diseases are prevalent in tropical
sequelae affecting the underserved and regions with Nigeria inclusive. Researchers, the
underdeveloped regions of the world. Despite their Non-Governmental Organizations, Governments
prevalence and clinical outcomes, they have not and other relevant stakeholders in the affected
received major research funding, curative measures regions must come together to curtail the menace of
or preventive methods because of they are not Neglected Tropical Diseases.
majorly a problem of the developed world. We set
out to review the various diseases in the Neglected Keywords: Tropical, Burden, Neglect, Diseases
Tropical Diseases spectrum with an aim to stimulate
academic interest, provide awareness and
contribute to the body of knowledge. Literature Introduction
search was done using keywords described above Neglected Tropical Diseases (NTDs) are infectious
on MedLine, PubMed, HINARI and Advanced diseases that are generally rare or absent in
Google search. Relevant articles were pooled and developed countries, but are often widespread in the
information was extracted and appropriately
developing world (Feasy et al., 2010). NTDs are a
referenced. Books and Journal hardcopies were
group of chronic, disabling, and disfiguring
also obtained from the Libraries of the Usmanu
Danfodiyo University, Sokoto. These were conditions that occur most commonly in the setting
referenced accordingly. The seventeen Neglected of extreme poverty especially among the rural, poor
Tropical Diseases as prioritized by the World Health and some disadvantaged urban populations (Hotez et
Organization were reviewed in terms of their al., 2006).
prevalence, areas affected, clinical presentation,
treatment and control measures. They are the One billion people suffer from NTDs worldwide.
American Trypanasomiasis (Chagas disease), However, NTDs are more common in 149
Human African Trypanasomiasis (Sleeping Countries. These illnesses affect both children and
sickness), Leishmaniasis, Leprosy, Trachoma,
adult, with children and women more vulnerable
Buruli Ulcer, Yaws, Dracunculiasis (Guinea worm
(WHO, 2012a). NTDs have a terrible impact on
disease), Lymphatic Filariasis (Elephantiasis),
Onchocerciasis (River Blindness), Schistosomiasis health, impede child growth and development, harm

pregnant women and often cause long-term Methodology

debilitating illnesses and are often deadly (WHO, Literature search were done using keywords
2012a). Deformities associated with NTDs such as described above on MedLine, PubMed, HINARI
Leprosy, Leishmaniasis and Lymphatic Filariasis and Advanced Google search. Relevant articles were
can become so severe that patients are banished pooled and information was extracted and
from their communities as well as the workforce. appropriately referenced. Books and Journal
Such deformities include the severely enlarge limbs hardcopies were also obtained from the Library of
of elephantiasis, the faces eroded by mucocutaneous the Usmanu Danfodiyo University, Sokoto. These
Leishmaniasis or Leprosy, and the limbs of small were referenced accordingly.
children that are amputated to save their lives from
aggressive Buruli ulcer. Sleeping sickness can Findings
permanently impair mental function and cause Description and aetiology of the major NTDs:
mental retardation, even in children who have been Seventeen (17) NTDs are prioritized by the WHO;
cured, and survivors of NTDs are often left these NTDs result from four main causative
permanently disabled, disfigured or blinded, and pathogens (Protozoa, Bacteria, Helminths and
many face a lifetime health complications (WHO, Virus). The Protozoan agents are; American
2009). trypanosomiasis (Chagas disease), Human African
Trypanasomiasis (Sleeping sickness) and
Many NTDs are transmitted by insects or Leishmaniasis. However, the Bacterial agents are
contaminated food and water in parts of the world Leprosy, Trachoma, Buruli Ulcer and Yaws. The
with poor sanitation, lack of hygiene and open Helminths are Dracunculiasis (Guinea worm
defecation are important risk factors for the disease), Lymphatic Filariasis (Elephantiasis),
transmission of many NTDs. Latest estimation Onchocerciasis (River Blindness), Schistosomiasis
indicates that more than 660 people do not have (Bilhazia), Soil Transmitted Helminths,
access to improve water source (WHO, 2015b). Echinococcosis, Cysticercosis/Taeniasis,
Effective sanitation, access to clean water supplies Fascioliasis. The Viral agents are Dengue virus and
and other non-pharmacological interventions Rabies virus.
(example use of bed net) help to prevent initial NTD
infection and help to prevent re-infection following The African Region bears about half of the global
effective treatment (Redy et al., 2007). burden of NTDs, some of these NTDs, including
Guinea worm disease, Buruli ulcer and Human
Feasey and Colleagues (2010) noted that there are African trypanosomiasis, affect only or mainly the
13 NTDs: Ascariasis, Buruli ulcer, Chagas disease, African Continent (Molyneux et al., 2005).
Hookworm infection, Dracunculiasis, Human Elephantiasis and Onchorcerciasis (River blindness)
African Trypanasomiasis, Leishmaniasis, Leprosy, are more common in Nigeria than any other
Lymphatic Filariasis, Onchocerciasis, Country, and no country anywhere has more cases
Schistosomiasis, Trachoma, and Trichuriasis. This of Schistosomiasis. Guinea worm has notably been
was supported by the World Health Organization eliminated (Adetokunbo, 2013). There is an
(WHO), Centre for Disease Control and Prevention increasing momentum to eliminate NTDs, following
(CDC) and infectious diseases expert (Fenwick, the WHO’s assembly’s adoption of resolutions on
2012) who recognized 12 core NTDs: Ascariasis, NTDs (WHO, 2012a).
Buruli ulcer, Chagas disease, Dracunculiasis,
Human African Trypanasomiasis, Leishmaniasis, Approximately 85% of NTDs burden results from
Leprosy, Lymphatic filariasis, Onchocerciasis, Helminth infections. Schistosomiasis is the second
Schistosomiasis, Trachoma and Trichuriasis. We set most prevalent NTD after Hookworm infection
out to review the agents, epidemiology and clinical accounting to 192 million cases. Lymphatic
manifestations of NTDs. Filariasis (46-51 million cases) and Onchocerciasis
(37 million cases), Human African trypanosomiasis

and Leishmaniasis affect 100,000 people while manifest such as massive swelling of the testicle,
Trachoma is the most prevalent Bacterial NTD (30 pain and swelling in the limbs (Ottensen et al.,
million cases) (WHO, 2015c). 2008). Mass drug administration needs to happen to
NTDs are prevalent in the tropics and subtropical eradicate the disease in the infected areas
climates of the world’s rural, vulnerable and poorest permanently (Keenan et al., 2013). Avoiding getting
population. Over half a million lives are lost each bitten by mosquitoes when in regions where there is
year as a result of NTDs (Phillip and Hotez, 2009). infection is the best (Michael and Bundy, 1997).
In recent years, there is an awakening about the
burden of NTDs. Schistosomiasis (Bilharzia): This is parasitic
disease which causes genital lesions amongst other
Reason for Neglect of NTDs lesions. It is caused by blood flukes (worms) that
The reasons for neglect is that this group of diseases use freshwater snails as an intermediate host. Early
have been overlooked because they mainly affect the signs are blood in urine or stool and anaemia and
poorest countries of the developing world and impaired growth and development in children, to life
because of recent emphasis on decreasing the threatening conditions including bladder cancer,
prevalence of HIV/AIDS, Malaria and Tuberculosis kidney malfunction and Cirrhosis (Steinmann et al.,
(Feasy et al., 2010). 2006). Schistosomiasis is prevalent in South
America, Asia and Africa. It affects more than 240
Fenwick (2012) also states that far more resources million people worldwide and 700 million people
are given to the “big three”, HIV/AIDS, Malaria, are at risk in 74 Countries of which 100 million are
Tuberculosis, because of their higher mortality and children (WHO, 2015b). The disease is contracted
public awareness rates. He states that the importance through consumption of water contaminated with
of NTDs has been underestimated since many are infected freshwater snails or through swimming in
asymptomatic and have long incubation periods and the contaminated water and poor sanitation
that the connection between a death and a NTD that (Steinmann et al., 2006). Symptoms are genital
has been latent for long period of time is not often lesions, abdominal pain, diarrhoea, fever, bladder
realized. According to the Financial Times, reason infections, lesions forming in the brain and spine
for neglect for these diseases is that they are not due to egg more. The disease can be controlled by
commercial and consequently patents and profit play treating infected people with Praziquantel which can
a role in stimulating innovation (Phillip and Hotez, be administered annually to people living in infected
2009). areas (James, 2009). Provision of proper sanitation
including adequate disposal of human faeces and
Lymphatic Filariasis (Elephantiasis): The disease urine (Steinmann et al., 2006).
is usually contracted during childhood and causes
horrific disfigurement in later life. It leads to Leishmaniasis: This is a disease caused by a
permanent disability from swollen limbs and breast Protozoan parasite resulting in horrendous skin
(Lymphedema), genital damage (Hydrocele), ulceration (Bern et al., 2008). It is common in South
swollen limbs with thickened, hardened skin and Central America, Asia, Africa and Southern
(Elephantiasis) (Michael and Bundy, 1997). A total Europe. Around 12 million people worldwide are
of 120 million people are currently infected in 73 currently infected and 20,000-50,000 die annually
countries (WHO, 2015c). The mode of transmission (WHO, 2015b). The mode of transmission is via the
is via Mosquitoes infected with the filarial parasite bite of Sand fly bite that thrives in areas with bad
(roundworms) that leave the larvae on the skin when sanitation or where garbage is left in the street.
they bite. The larvae enter the skin and travel via the Symptoms are Skin ulcers, which depending on the
Lymphatic vessels growing into adult worms in the form of the disease, can include mouth and nose
lymphatic system (Donald et al., 2002). Infected ulceration causing permanent mutilation of the
persons usually have no idea they are infected with throat and airways, enlargement of the spleen and
it until adolescence before the symptoms starts to liver and death (Shaw, 2007). The disease can be

controlled by using bug nets, sprayed or Human African Trypanosomiasis (Sleeping

impregnated repellent while sleeping. The drugs Sickness): This is a Protozoan parasitic disease
used and their effectiveness depends upon the region spread by the bite of the Tsetse fly in impoverished
where the disease was contracted (Bern et al., 2008). rural areas of sub-Saharan Africa. It is one of the
most complex Endemic Tropical diseases (Black
Onchocerciasis (River Blindness): This is a disease and Seed, 2001). About 60 million people in Africa
that is caused by parasitic worms transmitted from are at risk of infection (WHO, 2012b). When
person-to-person by black flies. The disease is symptoms developed, the patient is already
prevalent in some parts of Latin America and 31 approaching the terminal stage of the disease that
African Countries. WHO estimates that about half a involves the Central Nervous System, causing the
million people have lost their eyesight due to River daytime drowsiness which gives the disease the
blindness (WHO, 2012a). Mode of transmission is name “Sleeping Sickness”. Initial symptoms include
via the bite of black fly that has become infected headache, fever, weakness, sweating, pain in the
from biting a person who is carrying the parasite. joints and stiffness (WHO, 2006). A number of
Each individual adult worm can live inside a person different drugs are required to treat Human African
for up to 15 years (Donald et al., 2002). The clinical Trypanasomiasis, Eflorinithine, Melarsopol,
manifestations are an insanely intense itching, skin Pentamidine, Nifurtimox and Suramin (Black and
disfigurement and lesions, visual problems and Seed, 2001).
blindness. Measure of control is mainly avoiding
being bitten by insects as there is no vaccine or other Dracunculiasis (Guinea worm Disease): This is a
preventative measures. River blindness is difficult to crippling disease caused by Dracunculus
diagnose since blood test are inconclusive. It takes Medinensis, a long threadlike worm. It is endemic in
up to 20 months after being bitten for the larvae to four Countries as of 2012; the countries are Chad,
be detected in the skin (Boatin and Richards, 2006). Ethiopia, Mali and South Sudan. An eradication
The Drug Ivermectin, Diethylcarbomazine and program has been able to reduce prevalence. The
Mectizan can be used to kill the adult worm (Hotez, infection has dropped from over 3 million cases per
2010). year in the 1980s to less than 2000 cases in 2010
(WHO, 2012b). It is transmitted exclusively by
Leprosy: This is a complex Bacterial infection drinking water contaminated with Water Fleas
caused by Bacillus Mycobacterium leprae. The (copecods) infected with Guinea worm larvae. Once
disease mainly affects the skin, peripheral nerves, inside the Human host, the larvae mature and
mucosa of the upper respiratory tract and the eyes. emerge from blisters in the skin (WHO, 2008b).
In Africa, the number of new cases of Leprosy has Approximately one year after infection, a painful
declined every year since 2001. At the beginning of blister forms and one or two worms emerge.
2008, approximately 30,055 cases of Leprosy were
registered in Africa with 31,037 new cases in 2007 The mode of prevention is by preventing people
(WHO, 2008c). The highest prevalence occurs in with emerging worms from entering water, cloth or
Democratic Republic of Congo (6,502 cases), pipe filters for drinking water, health education and
followed by Nigeria (5,381), Ethiopia (4,611) and treating ponds with Larvicides. The wounds should
Mozambique (2,610). It is also found in Angola, be cleaned and bandaged and the worm pulled
Brazil, Central African Republic, India, Madagascar, gradually (WHO, 2008b).
Mozambique, Nepal and Tanzania (WHO, 2012b).
Symptoms are mainly damage to the skin, nerves, Trachoma: This is a bacterial infection caused by
eyes and limbs. Leprosy can now be cured easily Chlamydia trachomatis, if left untreated this
using multidrug therapy. Early diagnosis and condition leads to the formation of irreversible
treatment with the Multi Drug Therapy remains the corneal opacities and blindness. It is the world’s
key elements in eliminating the disease (Keenan et leading cause of preventable blindness (WHO,
al., 2013). 2008d). The disease is prevalent in Africa, Asia,

Central and South America, Middle East and Trichuriasis, Necator americanus and Ancylostoma
Australia. There are 21.4 million people infected duodenale (Hookworm) causes Hookworm infection
with Trachoma, of whom, 2.2 million are partially (Drake et al., 2008). STH occurs in sub-Saharan
blind and 1.2 million are blind (WHO, 2015b). It is Africa, the Americas, China and East Asia.
transmitted through contact with eye discharge from Approximately one-third of the world Hookworm
an infected person, particularly in young children. It infection occurs in the sub-Saharan Africa, with the
is also spread by flies that have been in contact with greatest number of cases occurring in Nigeria (38
the eyes and nose of infected people (Hotez and million), Democratic Republic of Congo (31
Abdallah, 2008). Symptoms are internally scarred million), followed by Angola, Ethiopia and Côte
eyelids, followed by eyelid turning inward. It is d'Ivoire (10-11 million) (WHO, 2015). The highest
treated with antibiotics mainly the Doxycyclines. intensity of Ascariasis and Trichuriasis infections
The main effective preventive method is inter- occur in school children with 173 million and 162
personal hygiene (WHO, 2008d). It is controlled by million people with Ascariasis and Trichuriasis
a strategy called SAFE (Surgery, Antibiotics, Face respectively (WHO, 2015b).
washing and Environmental change) (WHO, 2012a).
STH are transmitted via exposure to infected Human
American Trypanosomiasis (Chagas Disease): This faeces and soil contaminated by it due to poor
is a parasitic infection caused by vector-borne sanitation and open defecation (Brooker et al.,
protozoa. It is prevalent primarily in South America. 2006). The most common symptoms are anaemia,
Approximately 15 million people are infected with stunted growth, Vitamin A deficiency, stunted
Chagas disease, 25 million people are at risk and growth, malnutrition, intestinal obstruction and
10,000 die each year from this disease, mostly from impaired development (Simon et al., 2008). Most
Cardiac complications (WHO, 2015b). effective treatments are Albendazole or
Mebendazole. It can be prevented through improved
Mode of transmission is via the Bug’s bite (Assassin sanitation, periodic deworming and health education
Bug) on skin breaks or mucous membranes. (Taylor et al., 2012).
Infection can also result from eating infected food or
coming into contact with contaminated bodily fluids, Yaws: This is a chronic bacterial infection that is
and also through blood transfusion, from Mother to caused by Treponemes. It causes disfigurement and
child, organ transplant (Albany, 2002). There are disability if left untreated (WHO, 2009). It is
two phases of clinical manifestations; the initial prevalent most in the warm, moist, tropical regions
acute phase which is asymptomatic. The first of the Americas, Africa, Asia and the Pacific (WHO,
symptoms are skin chancres, unilateral purplish 2015c). There are limited data available on the
orbital oedema, local lymphadenopathies, and fever. prevalence of Yaws. It is transmitted through skin
The chronic phase is cardiac and digestive lesions contact with infected individuals. The most common
(Albany, 2002). The preferred treatment of acute symptom is skin lesions that lead to permanent
Chagas Disease is a 60 days’ course of disfigurement (Hotez and Abdallah, 2008). It is
Benznidazole, or as second-line treatment, a 60-90 treated with antibiotics like the Penicillins,
days’ course of Nifurtimox (Hotez, 2010). It can be Cephalosporins or the Quinolones (Keenan et al.,
prevented by avoiding insect bites through 2013). Prevention can be achieved through
insecticide spraying, home improvement, bed nets improved hygiene and sanitation (WHO, 2015c).
and medical care (Albany, 2002). Cysticercosis and Taeniasis: Cysticercosis is an
adult tapeworm infection, whilst Taeniasis is a
Soil Transmitted Helminthiasis (STH): These Tapeworm larvae infection. Cysticercosis is the
include parasitic worms, the major worm species most common preventable cause of epilepsy and
responsible for soil transmitted helminthiasis are neurocystocercosis can be fatal (Hotez and
Ascaris lumbricoides (Roundworms) causes Abdallah, 2008). Both diseases are found in Asia,
Ascariasis, Trichuristrichura (Whipworm) causes Africa and Latin America, particularly on farms in

which pigs are exposed to human excrement (WHO, months’ incubation period. Furious (the more
2015a). Cysticercosis is contracted after eating common type) Rabies causes hyperactivity,
undercooked contaminated pork. Taeniasis occurs hydrophobia, aerophobia and death by cardio-
after ingestion of contaminated food, water or soil respiratory arrest within days. Paralytic Rabies
(Philip and Hotez, 2009). Cysticercosis involves causes a slow progression from paralysis to coma to
cysts and lesions that can cause headache, blindness, death (Knobel et al., 2005). Cleaning and
seizures, hydrocephalus, Meningitis and Dementia. disinfecting bite wounds. It can be prevented
Taeniasis has mild symptoms including abdominal through the vaccination of Humans and Dogs
pain, nausea, diarrhea or constipation (WHO, (WHO, 2014).
2015a). Both diseases can be treated with drugs,
usually Praziquantel or Niclosamide (Keenan et al., Buruli Ulcer: The risk of mortality is low, although
2013). Infection can be prevented through stricter secondary infection can be lethal. Morbidity takes
meat inspection standards, livestock confinement, the form of deformity and disability (Walsh et al.,
improved hygiene and sanitation, health education, 2008). It is prevalent in Africa, Asia, and Latin
safe meat preparation and identifying and treating America (WHO, 2012a). In Africa estimated cases
Human and Pig carriers (Phillip and Hotez, 2009). of Buruli ulcer are 7000, with the largest number
reported from the West African countries of Côte
Echinococcosis: There are two versions of the d'Ivoire (2000 cases), and Benin and Ghana (1000
disease; Cystic Echinococcosis and Alveolar cases each) (WHO, 2012b). The disease is caused by
Echnicoccosis. Cystic Echinococcosis is found in bacteria. The greatest risk factors for acquiring
Mediterranean region, Northern Africa, Southern Buruli ulcer include residing in an endemic area,
and Eastern Europe, Southern portion of South close proximity to specific bodies of water and age
America and Central Asia. Alveolar Echinococcosis less than 15 years (WHO, 2008a). Symptoms are
is found in North America, Western and Central skin swellings and lesions. It is treated with
China, Russia and Europe. More than one million antibiotics (Streptomycin and cell wall active
people are currently affected (WHO, 2015c). It is agents) and surgery (Hotez, 2010).
caused by ingesting parasites in animal faeces. In the
Cystic version, liver cyst cause abdominal pain, Fascioliasis: Fascioliasis is a food borne Trematode,
nausea and vomiting, while cyst in the lungs cause also known as common Liver-Fluke. Fascioliasis is
chronic cough, chest pain and shortness of breath. In currently a health concern in more than 70 countries.
Alveolar version, a primary cyst develops, usually in Millions of people are infected, and estimates of 180
the liver, in addition to weight loss, abdominal pain million are at risk (WHO, 2015b). People living in
and general feeling of ill health and signs of liver rural, agricultural villages in the Andean highlands
failure (WHO, 2009). Surgery and Drugs can be of Bolivia and Peru have the highest rates of
used for treatment (Hotez, 2010). It can be infection. In Endemic countries, school children are
prevented by deworming dogs, sanitation, proper at the highest risk of infection (WHO, 2012a).
disposal of animal faeces, health education and Clinical manifestations are abdominal pain, fever,
livestock vaccine (Phillip and Hotez, 2009). vomiting, diarrhea that can last for months. Human
infection occurs primarily through the ingestion of
Rabies: There are two forms of Rabies; Furious and Fasciola larvae attached to raw or uncooked
Paralytic (Knobel et al., 2005). It is found in Asia vegetables, or floating in drinking water (Hotez and
and Africa. There are 60,000 deaths from Rabies Abdallah, 2008). It is treated using a single dose of
annually. There is a higher prevalence in rural areas the medicine Triclabendazole. Prevention can be
and it disproportionately affects children (WHO, through proper cooking of food and drinking water.
2015c). It is caused by lyssavirus transmitted (Molyneux, 2006).
through the wounds of bites from infected animals
(WHO, 2014). The initial symptoms are fever and Dengue Fever: Is caused by a Flavirus. Dengue
pain near the infection site which occur after 1-3 fever is usually not fatal, but infection with one of

the four serotypes can increase later susceptibility to Programme for Research and Training in
other serotypes, resulting in a potentially fatal Tropical Diseases (TDR), 1976-1986.
disease called Severe Dengue (WHO, 2012a). The Albany, N.Y. (2002). Control of Chagas Disease.
disease is prevalent in Asia, Latin America, and WHO Expert Committee. New York, USA;
Northern Australia. There are 50-100 million World Health Organization. WHO Technical
Dengue Fever infections annually (WHO, 2015c). It Report Series; 905.
is spread by the bite of Aedes. Aegypti mosquito. Bern, C., Maguire, J.H., and Alvar, J. (2008).
Clinical manifestations are high fever and flulike Complexities of assessing the disease burden
symptoms. There is no treatment for Dengue or attributable to Leishmaniasis. Neglected
severe Dengue (Redy et al., 2007). Prevention of Tropical Diseases; 2 (10): 313.
Dengue virus is to effectively combat the vector Black, S.J., and Seed, J.R. (2001). The African
mosquito (Hotez et al., 2007). There is an increasing Trypanasomiasis. New York, Boston,
momentum to eliminate NTDs, following the WHO Dordrecht London, Moscow. Kluer Academic
Assembly’s adoption of resolutions on NTDs and a Press.
considerable progress has been made in the fight Boatin, B.A., and Richards, F.O. (2006). Control of
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distribution of NTDs (Brooker and Michael, 2000). of Geographical Information Systems and
The overall burden of NTDs may be severely Remote Sensing in the epidemiology and
underestimated. A full assessment is an important control of Human Helminth Infections.
step to disease control priorities; particularly in areas Advanced Parasitology; 47:245-288.
were the greatest number of NTDs may occur Drake, L.J., Jukes, M.C., Steinberg, R.J., and
(Hotez, 2010). These diseases are contrasted with Bundy, D.A.P. (2008). Geohelminth infections
the big three diseases (HIV/AIDS, Tuberculosis, and (Ascariasis, Trichuriasis, and Hookworm):
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(WHO, 2012a). Controlling NTDs can have a diseases: could they be consigned to history’.
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Original Research
SJMLS-2(1)-2017-006
Pancreatic enzymes activities in Human Immunodeficiency virus-1
infected subjects in Benin City, Nigeria.
Emokpae, M.A. * 1, Nwokedi D.O. 1
Department of Medical Laboratory Science, School of Basic Medical Sciences, College of Medical Sciences,
University of Benin, Benin City, Nigeria 1.
Author for correspondence*: mathias.emokpae@uniben.edu/+234-08034511182.
Abstract activities of the HIV-1 positive subjects should be

Pancreatitis is a known complication of human routinely evaluated in this group of subjects.
immunodeficiency virus-1 (HIV-1) infection even in
this era of highly active anti-retroviral therapy Keywords: Human Immunodeficiency virus-1
(HAART). There is however conflicting report infection, serum amylase, lipase and urine amylase.
regarding the activity of serum amylase, lipase and
urine amylase in HIV-1 positive subjects on HAART. Introduction
Despite the fact that pancreatitis has been reported Human immunodeficiency virus-1 (HIV-1) infection
in HIV-1 infection, serum levels of these enzymes is one of the most prevalent chronic infectious
are rarely routinely evaluated as part of the clinical
diseases, causing significant morbidity and mortality
assessment of these patients. The aim of this study
worldwide. According to the World Health
was to evaluate the activities of serum amylase,
lipase and urinary amylase in HIV-1 infected Organization estimation, 3.2 million persons are
subjects. A total of 150 participants comprising of infected with HIV/AIDS in Nigeria, giving a
100 HIV-1 positive subjects (40 males and 60 prevalence of 3.2% (UNAIDS, 2014). Studies have
females) and 50 HIV-1 negative controls (20 males shown that apart from symptomatic increase in
and 30 females) were enrolled in the study. Serum pancreatic enzymes, unexplained elevation of
amylase, lipase and urine amylase activities were pancreatic enzymes without clinical evidence of
assayed by spectrophotometric methods using pancreatitis have been reported (Argiris et al., 1999;
commercially available reagent kits. Cluster of Bonacini, 1991; Dowell et al., 1990; Schwartz and
+
differentiation 4 (CD4 ) cell counts were determined
Brandt, 1989). Whereas some authors attributed the
using BD FACSCount system (Becton and
elevation of the pancreatic enzymes to pancreatic
Dickinson’s Company, California, USA). Statistically
significant higher levels (p<0.001) of serum pathology as a result of opportunistic infections
amylase, lipase and urine amylase (p<0.05) were (Argiris et al., 1999) and HIV virus (Moore and
observed in HIV-1 positive subject on HAART and Schneider, 2013). Others however, attributed such
HAART naïve compared with HIV-1 negative elevation to the use of antiretroviral (monotherapy)
controls. Serum amylase correlated positively with drugs (Maxson et al., 1992).
+
CD4 cell count in HIV-1 positive subjects on
HAART. HIV-1 positive subjects evaluated in the The introduction of highly active antiretroviral
study had higher activity levels of pancreatic therapy (HAART) in the treatment of the disease has
enzymes. Pancreatitis should always be considered
reduced mortality and morbidity of the infected
in HIV-1 positive subjects especially in those with
subjects. It is a combination of drugs with different
abdominal pain. Therefore, the pancreatic enzymes
actions. They are divided into 5 classes which
includes Nucleoside/Nucleotide reverse transcriptase

inhibitors (NRTIs/NtRTIs), Non-nucleotide reverse randomly selected from the anti-retroviral therapy
transcriptase inhibitors (NNRTIs), Fusion inhibitors clinic of Central Hospital, Benin City from May to
(FI), Integrase inhibitors (II) and Protease inhibitors August 2016. The participants comprised of 50
(PI) (Teixeira et al., 2011). They help to reduce confirmed HIV-1 positive individuals receiving
morbidity and to prolong the lives of persons living HAART (20 males and 30 females with age range of
with HIV, enhance immunity by increasing CD4 20-55years), 50 newly diagnosed HIV-1 positive
count, achieve rapid and sustained suppression of HAART naïve (20 males and 30 females with age
viral load and also reduce the risk of transmission range of 20-50 years) and 50 HIV-1 negative
from mother to child (Anderson et al., 2008; Reisler apparently healthy individuals (20 males and 30
et al., 2005). Despite the fact that HAART has been females with age range of 20-50 years).
effective in the management of HIV, HIV-infected
patients continue to have multiple potential risk Ethical consideration: The protocol of the study
factors for subclinical or clinical pancreatic was reviewed and approved by the Edo State
involvement (Reisler et al., 2005; Moore et al., Ministry of Health (ethical code HM.1208/112 dated
2001). In some studies, it was reported that HAART 12th May 2016).
has a wide range of adverse effects, which also
includes drug-induced pancreatitis (Teixeira et al., Inclusion and exclusion criteria
2011). Elevated amylase and lipase as a result of Confirmed HIV-1 positive subjects who were on
long- term antiretroviral therapy can lead to acute routine visit to the anti-retroviral clinic of the
pancreatitis which is potentially a life-threatening Central Hospital and who gave verbal informed
condition that is characterized clinically by consent were included in the study. HIV negative
abdominal pain, nausea and vomiting (Sah et al., subjects who had gastrointestinal illness or infection,
2012). The effects of HAART on the levels of those who did not give consent or self-reported
pancreatic enzymes activities in HIV-1 infected HIV-1 positive individuals as well as those with
subjects are not completely known. Earlier studies AIDS were excluded.
have reported elevated levels of pancreatic enzymes
in HIV-1 positive subjects (Argiris et al., 1999; Sample Collection
Cappell, 1994; Bonacini, 1991; Dowell et al., 1990 Clinical data with other relevant demographic
and Schwartz and Brandt, 1989). Recently, a information were obtained. Under strict aseptic
contradicting observation was reported by Szoke precautions, 5ml of venous blood was obtained from
and Colleagues (2016). They observed that the each participant and 2mL was transferred into
frequency of pancreatic amylase increase did not EDTA container which was used for CD4 cell count
significantly differ between HIV-1 positive subjects using FASCount auto-analyzer (Becton Dickinson,
on HAART and HIV-1 positive HAART naïve. USA) while the remaining 3mL was emptied into a
Also, it was observed that in some HIV-1 positive plain tube. The sample collected in the plain tube
subjects with elevated serum amylase, the lipase was allowed to clot at room temperature and was
activity was normal. Since the earlier publications centrifuged at 1000g for 5 minutes. The serum was
that reported elevated levels of pancreatic enzymes separated into another plain tube and kept frozen at -
were conducted either before the introduction of 20oC until analyzed. The amylase and lipase
antiretroviral drugs or in those that were on activities were assayed using commercially available
antiretroviral monotherapy, this present study seeks reagent kits (Agape Diagnostics, Switzerland).
to investigate the activities of pancreatic amylase Random urine samples were also collected in
and lipase in HIV-1 positive subjects on HAART universal containers and were used for the assay of
and HAART naïve. urine amylase activity. The reference ranges of
serum amylase were 30-86U/L, lipase 20-80U/L and
Materials and Methods urine amylase was 24-470U/L.
Selection of study participants: All study
participants who met the inclusion criteria were

Quality Control: In order to ensure accurate and

precise results, quality control sera were included in Results
the assays. The control sera used were: ACUSERA The results are presented in tables 1, 2 and 3. Table
Premium plus (RANDOX, UK) (Cat No: AY1580): 1 shows that the serum amylase and lipase activities
For amylase with a measuring range of 7.3-1509 were significantly higher (p<0.001) in HIV-1
U/L. ACUSERA Premium 3 (Cat No: LI3837), for positive on HAART than HAART naïve and
lipase with measuring range of 8.85-744 U/L and controls. Also, serum amylase and lipase activities
BD FACSCount control beads for CD4+ cell counts were significantly higher (p<0.001) in HIV-1
(0 beads/ μL; 250 beads/ μL and 1000 beads/ μL). positive HAART naïve compared with controls.
Urine amylase activity was significantly higher
Statistical analysis (p<0.05) in HIV-1 positive subjects on HAART
Statistical analysis was done using the statistical compared with HIV-1 positive HAART naïve and
package for social sciences (SPSS) version 16.0. All control subjects. There was no significant
values were expressed as Mean ± Standard error of difference in the measured enzymes activities
the mean. The Students’-test and analysis of between male and female HIV-1 positive subjects
variance (ANOVA) were used to compare the mean (table 2). Table 3 shows that the CD4+ cell count
values of the observed measured parameters correlated positively with serum amylase while
between the groups. Pearson correlation coefficient serum lipase and urine amylase activities showed no
was used to test the association between CD4+ cell significant correlation with CD4+ count.
counts with enzymes. A p-value of ≤0.05 was
considered to be statistically significant.
Table 1: Comparison of measured enzyme activities in HIV-1 positive individuals on HAART, HAART-
naïve and controls (mean±SEM).
Measured enzyme HIV-1 positive HIV-1 positive HIV-1 negative p-value
activities subjects on subjects control subjects
HAART HAART naïve (n=50)
(n=50) (n=50)
Serum amylase (U/L) 128±5.0a 84±4a 63±2 0.001
Serum lipase (U/L) 83±4a 69±3a 55±2 0.001
b c
Urine amylase (U/L) 178±14 128±8 136±11 0.05
+ ab a
CD4 count(cells/µL) 488.1±12.7 298.8±9.9 789.9±10 0.001
a=p<0.001; b=p<0.05; c=p>0.05
Table 2: Comparison of measured enzyme activities between male and female HIV-1 positive subjects
(mean±SEM).
Measured enzyme activities HIV-1positive HIV-1 positive p-value
male subjects female subjects
(n=40) (n=60)
Serum amylase (U/L) 96±6 98±5 0.768
Serum lipase (U/L) 69±3 74±3 0.259
Urine amylase (U/L) 160±12 142±7 0.187
+
CD4 count(cells/µL) 248±10 344±18 0.001

Table 3: Correlation of CD4+cell count with measured enzyme activities

Measured enzyme activities R-values p-value
Serum amylase 0.386 0.001
Serum lipase 0.075 0.508
Urine amylase -0.020 0.862
Discussion very high viral load (Moore and Schneider, 2013).

Amylase and lipase are enzymes that are essential This was an indication that the observed elevation of
for health and wellbeing of human beings as they are pancreatic enzymes may be due to HIV infection
involved in the digestion of carbohydrates and lipids (Moore and Schneider, 2013). On the other hand,
respectively. our observation is at variance with a previous report
(Szoke et al., 2016). These authors observed that the
Pancreatitis is a common complication among HIV- frequency of pancreatic amylase increase was not
1 infected individuals on HAART and a common significantly different between HIV-1 positive and
cause of morbidity and occasional mortality the general population (HIV-1 negative individuals).
(Dassopoulos and Ehrenpreis, 1999). The conflicting In the same vein, they reported that there was no
reports in literature regarding the activity levels of significant difference between HIV-1 positive
pancreatic enzymes in HIV-1 positive individuals subjects on HAART and HIV-1 positive HAART
were attributed to inconsistencies in the collection naïve. They further observed that in about 48% of
and analysis of clinical and laboratory data as well HIV-1 positive subjects with high serum amylase
as lack of long- term follow-up (Raza et al., 2013). activity, lipase was normal suggesting that the
It was therefore suggested that pancreatitis among increased amylase was not of pancreatic origin
HIV-1 infected subjects on HAART require frequent (Szoke et al., 2016).
revisits (Cappell and Hassan, 1993). In this study,
serum amylase and lipase activities were Our observation may suggest the presence of silent
significantly higher in HIV-1 positive subjects than pancreatic involvement which was indicated by
controls. Also, the activities of serum amylase and higher serum amylase and lipase activities than
lipase were significantly higher (p<0.001) in HIV-1 controls. In a study of biochemical assessment of
positive subjects on HAART than HIV-1 positive pancreatic disease in HIV infected men, it was
HAART naïve subjects. The observed higher observed that total amylase is a poor indicator of
enzyme activities (serum amylase and lipase) in pancreatic disease. Pancreatic amylase was therefore
HIV-1 positive subjects observed in this study is in suggested as a better marker than traditional total
agreement with previous studies (Manfrendi et al., amylase especially when lipase activity is added.
2004; Moore et al., 2001; Argiris et al., 1999; The addition of lipase assay could improve the
Cappell, 1994 and Maxson et al., 1992) which biochemical identification of HIV-1 subjects with
indicated a significant increase in serum amylase possible pancreatic disease (Hancock et al., 1997).
and serum lipase in HIV-positive subjects and
attributed the cause of the increase to HIV infection The significantly higher levels of serum amylase,
and medications used in the treatment of lipase and urine amylase in HIV-1 positive subjects
opportunistic infections. The reasons for the on HAART compared to HIV-positive HAART
significantly higher activities levels of serum naïve subjects may be due to the effects of HAART
amylase and serum lipase in HIV-1 positive naïve drugs. The participants were on combination
subjects are not completely clear. It was reported therapy, which included Lamivudine, Nevirapine
that HIV-1 infection may cause elevation of and Zidovudine, as well as Efavirenz, Lamivudine
pancreatic enzymes even without HAART and Tenofovir. Previous studies have associated
treatment. Elevation of pancreatic enzymes activities pancreatitis with Nucleosidase Reverse
was reported in subjects suffering from an acute Transcriptase inhibitors (NRTIs) especially
HIV-1 infection with HIV negative serology but Didanosine and Stavudine (Dassopoulos and

Ehrenpreis, 1999 and Cappell and Hassan, 1993). counterparts. Conversely, a significantly higher
Other authors have questioned the relationship levels of pancreatic enzymes activities was reported
between pancreatitis and use of combination among females than males (p<0.05) (Riedel et al.,
HAART therapy. Raza and Colleagues (2013) 2008).
reported that only one third of their study
participants with pancreatitis were on HAART and A positive correlation was observed between serum
only a handful of the subjects were on pneumocystis amylase (r = 0.386, p = 0.001) and CD4+ count. This
carinii pneumonia (PCP) prophylaxis. This may indicated that serum amylase increased with
suggest other risk factors other than HAART use increasing levels of CD4+ count. The positive
that are contributing to the development of acute correlation is in agreement with a study that was
pancreatitis in HIV-1 infection (Oliveira et al., carried out elsewhere in Nigeria (Onochie et al.,
2014). Our observation of higher pancreatic 2007). It was reported that HAART succeeded in
enzymes levels in HIV-1 infected subjects on improving the immune status of the patients by
HAART compared to HAART naïve is consistent increasing their CD4+ count at the expense of the
with previous studies (Marques et al., 2015; pancreas which was affected negatively by the drug
Chehter, 2014 and Chehter et al., 2000). These use.
authors reported in autopsy studies that
morphological changes in endocrine pancreas of In this study, it was observed that while
patients who were taking HAART did take place. antiretroviral treatment was efficacious in improving
The observed changes in pancreas particularly in the the immune system of the infected subjects, it could
number and volume of pancreatic islets in be harmful, due to its toxic effects and including
individuals who were on HAART compared to HAART drug-induced pancreatitis. This can be seen
HAART naïve (Chehter, 2014 and Chehter et al., in the significant elevation of pancreatic enzymes
2000). Reduction in zymogen granules in more than activities (even though the levels of the measured
50% of the arcinar cells, parenchymal atrophy, enzymes were within reference range) in HIV-
steatosis and nuclear abnormalities were also positive subjects on HAART. HIV-1 positive
reported in HAART naïve HIV-1 patients (Chehter HAART naïve subjects are also vulnerable to
et al., 2000 and Chehter, 1997). Previous studies pancreatitis since enzymes activities were also
observed that patients who used Zidovudine in elevated in this group of participants.
combination regimen had more than two-fold
pancreatic enzymes elevation (Agiris et al., 1999). Conclusion
Also, other studies attributed the elevation of serum Based on the results of this study, it could be
amylase and lipase activities in HIV-1 positive concluded that HIV-1 positive subjects had higher
subjects on HAART to antiretroviral treatment levels of pancreatic enzymes activities, which may
(drugs- induced pancreatitis or HAART toxicity) be due to HAART use and HIV infection. The
(Manfrendi et al., 2004; Moore et al., 2001). pancreatic enzymes activities of the HIV-1 positive
patients should be routinely monitored, especially in
There was no gender dimorphism in the activities of patients on HAART and those showing symptoms of
the measured enzymes since no significant pancreatitis.
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Original Research
SJMLS-2(1)-2017-007
Knowledge, attitude and utilization of intermittent preventive
treatment for malaria among pregnant women attending antenatal
clinic in Usmanu Danfodiyo University Teaching Hospital(UDUTH)
Sokoto.
Ikpeama Chizoba Anthonia 1, Ikpeama Chinwe Joy 2, Ikpeama Osita John 3, Ogwuegbu Julie Uchechi 4
Federal Medical Centre Birinin Kebbi 1, School of Nursing, School of Post-Basic Midwifery Usmanu
Danfodio University Sokoto 2, Department of Public Health Imo State University Owerri 3, Department of
Medicine Imo State University Owerri 4.
Author for Correspondence: ikpeama35@gmail.com/ +234-806-261-9025
Abstract malaria but utilization is low due to factors such as

Intermittent preventive treatment for the prevention non-adherence to DOT strategy by the health facility
of malaria in pregnancy (IPTp) is the key component and belief that IPTp drugs may side effects.
of malaria control strategy in Nigeria and Concrete effort should be made by the facility to
sulphadoxine-pyrimethamine is the drug of choice. adhere to DOT strategy by training health workers
Malaria contribute to 11% maternal death in Nigeria. on IPTp approach. There is also need to educate
The study is set out to assess the knowledge, pregnant women about IPTp drugs to prevent
attitude and utilization of IPTp by pregnant women misconceptions and hence improve the utilization of
attending antenatal clinic in UDUTH. Finding from IPTp by pregnant women.
this study can be used by health policy makers to
implement policies that can potentially facilitate good Keywords: Knowledge, Attitude, Utilization,
knowledge, attitude and utilization of IPTp. This Intermittent Preventive Treatment, Malaria, Pregnant
descriptive survey research was carried out among Women, Usmanu Danfodiyo University Teaching
349 pregnant women selected by systematic Hospital, Sokoto.
random sampling technique from antenatal
attendees at UDUTH. Information on knowledge, Introduction
attitude and utilization of IPTp among pregnant
Malaria contributes to 11% maternal death in
women was obtained using a closed ended
Nigeria. Malaria remain a major public problem in
questionnaire. Descriptive statistics of percentage
sub-Saharan Africa with 80% of malaria cases and
was used. All analysis was performed at 95% level
of significance. 216 out 349 (73.5%) knew that IPTp 95% malaria mortality worldwide occurring in this
is used to prevent malaria, 162 out of 349 knew region (Snow et al., 1999 and WHO, 1996). It is
fansidar was a type of drug used for IPTp and 180 of estimated that 81% or 174 million cases were in the
the respondents know when the IPTp drugs are to African region and about 91% being due to
be giving to pregnant women, while 114 knew that Plasmodium falciparum followed by the South-East
IPTp drugs is taken by pregnant women in their 4-6 Asia 13% and Eastern Mediterranean region 5%
months’ pregnancy. The major source of information (Global Malaria Action Plan, 2011). These women
on IPTp was television. In conclusion, it has been
are infected with plasmodium falciparum, the most
made known from this study that the respondents
virulent plasmodium with serious health
have good knowledge and attitude towards IPTp for

consequences include anaemia, impaired foetal for malaria by pregnant women attending antenatal
growth, still birth and premature delivery (Onaka et clinic in Sokoto, Nigeria.
al., 2012).
Objective of the study
Intermittent preventive treatment of malaria in 1. To assess the knowledge of pregnant
pregnancy (IPTp) using sulphadoxine, women attending antenatal clinic on
pyremethamine (SP) was approved by the World intermittent preventive treatment of malaria
Health Organization. This is based on the 2. To assess the attitude of pregnant women on
assumption that every pregnant woman living in an intermittent preventive treatment of malaria
area of higher malaria transmission has symptoms of 3. To assess the utilization of IPTp by pregnant
malaria. The approach allows mother to take an women.
entire treatment dose (double dose) of an anti- 4. To identify the factors that influences the
malaria drugs during an antenatal care visit under utilization of IPTp among pregnant women.
the case and the supervision of health care provider
and is recommended to be administered in second Significance of the study
and third trimester of pregnancy during antenatal Data generated from this study can be used to
care visit (Akinyele, 2009). potentially improve the knowledge, attitude and
uptake of IPTp so as to reduce incidence and
Intermittent preventive treatment (IPTp) using complications of malaria among pregnant women. It
sulphadoxine and pyrimethamine is targeted to be will also enable policy makers formulate policies
given to those of low gravity (first and second that will help optimize the care offered to pregnant
pregnancy) persons with sickle cell disease and women in the area.
unexplained anaemia and the dosage should be a
single adult dose which is three tablet of 500mg Research question
sulphadoxine and 25mg pyrimethamine each at 1. What is the knowledge of pregnant women
scheduled antenatal visit during the second and third in Usmanu Danfodiyo University Teaching
trimesters or at least one month apart (Adesokan, Hospital (UDUTH) about intermittent
2011). treatment for malaria.
2. What is the attitude of pregnant women in
Despite the evidence of the effectiveness of UDUTH on the intermittent preventive
intermittent preventive treatment of malaria strategy treatment for malaria.
using sulphadoxine and pyrimethamine (SP) in 3. What is the utilization of intermittent
reducing the adverse effect of malaria during preventive treatment for malaria among
pregnancy, utilization and courage in Nigeria is low, pregnant women in UDUTH.
likewise in area of the study IPTP courage is low 4. What are the factors influencing the
since most of the pregnant women are reluctant. The utilization of intermittent preventive
study set out to assess the knowledge, attitude and treatment for malaria among pregnant
the uses of intermittent preventive treatment of women in UDUTH.
malaria during pregnancy among pregnant women
attending antenatal care visit and determine the Scope and limitation of the study
factor influencing IPTp and its effectiveness. The study is limited to pregnant women within 24-
36 weeks of gestation attending the Antenatal Clinic
Statement of problem (ANC) during the period of study so as to have
The increase cases of preterm labor/delivery seen in wider coverage. The limiting factors to this study are
the labor room were assumed to be caused by time, finance and the Federal Ministry of Health
malaria infection. Thus, the aim of the research is to policy of administering IPTP drugs to pregnant
determine or ascertain the knowledge, attitude and women of gestational age 20-36 weeks.
the utilization of intermittent preventive treatment

Research Design Sample size(n)= 3000/ (1+3000*0.05*0.05) = 3000/

A descriptive survey research design was used to (1+7.5)
collect data at the antenatal clinic of the Usmanu =3000/8.5
Danfodiyo University Teaching Hospital, Sokoto. =353
Sample size for this research =353
Setting and Area of Study
The study was carried out at the antenatal clinic of Sampling Technique
Obstetric and Gynecological Department of Usmanu A systematic sampling technique was employed in
Danfodiyo University Teaching Hospital Sokoto, this study after the women were stratified into four
Nigeria. The hospital is located along Gawon Nama, groups and every fourth person selected randomly
Wamakko local government area of Sokoto state in from each group from number 1 – 5, and this was
the Northern part of Nigeria. The hospital was done daily at every antenatal visit for a period of
among the group of teaching hospitals that was four weeks.
established in May 1980 as second generation
teaching hospital. The Department is located on the Instrument for Data Collection
North-Eastern part of the hospital and it consist of The instrument employed in this study for the
the Obstetric and Gynecological ward, pre-eclamptic collection of data was a structured questionnaire
toxemia ward, fertility research unit, gynecology with closed ended questions and interview. The
emergency clinic, antenatal clinic, side laboratory, questionnaire consists of three sections; A, B and C.
ultra-sonographic unit and a dedicated theatre. It is A. Socio-economic demographic
one of the most equipped health institution within characteristics.
the state. The clinic (antenatal clinic) is directly B. Knowledge of pregnant women on IPTp.
located under the labor room opposite the former C. Attitude and utilization of pregnant women
gynecological ward. Antenatal clinic days is from on IPTp.
Monday to Fridays and the clinics are run as two Section A was aimed at gathering details of the
shifts in a day (morning and evening shifts) with participant’s social, economic and demographic
Wednesday set aside as booking days. characteristics. Section B attempted to assess the
The antenatal clinic is being managed by a knowledge of pregnant women on IPTp, section C
professor, several Consultants, Registrars, House- of the questionnaire focused on the attitude and
officers in four teams (A, B, C and D) and utilization of pregnant women on IPTp.
midwives. There are about 12 trained midwives in
the clinic. The clinic has nurses’ station, Validity/Reliability of Instrument
reception/waiting scale section cubicle, three A pilot study was conducted by pretesting of the
palpation room, a side laboratory and gynae sampled close-ended questionnaires among ten
emergency section. pregnant women who attended antenatal clinic and it
was finalized by putting in ideas from the pretest
Target Population and producing the ones to be administered.
The target population were consenting pregnant
women that attended the antenatal clinic in UDUTH Method of Data Collection
over a four week in the month September. The total Information (data) was collected using interviewer-
population is estimated to be 3000. To get the administered questionnaire, the questionnaire is
sample size, we used the Solvin’s formula (Altares written in English. The questionnaire, was given to
et al., 2003) sampling technique which is: the respondents after obtaining verbal informed
Sample size (n) = N /(1=Ne^2) consent and were retrieved immediately it was
Where = n = sample size answered and filled by the researcher and her trained
N = Total population (two) assistance daily during the antenatal clinic
E=error tolerance (using 95% level of confidence) days for a period of four weeks.
our error tolerance is 0.05

Method of Data Analysis that they can opt-out anytime in the process, that the
Data collected were analyzed using descriptive research will cause no harm on them and that every
statistic of frequency count, normative percentage information given will be kept confidential.
and grand mean, the data analysis was presented
using statistical tables and figures. Data Presentation and Analysis
The summary of the findings from the survey is
Ethical Consideration presented under the following topics, socio-
Ethical permission was obtained from the Principal demographic characteristics of the respondents,
of School of Nursing. Informed consent was level of knowledge of respondents about IPTp,
obtained from each respondent before the interview attitude of respondents to IPTp, utilization of
and before questionnaire was given. The ethical respondents to IPTp and factors influencing the
principle of autonomy, normalificience and IPTp utilization. A total of 353 questionnaires was
confidentiality of the patient was maintained as the administered but 349 was analyzed and presented,
respondent was told that it is not compulsory and the rest (4) were not filled properly.
Table 1: Knowledge of Respondents on IPTp

Component of Knowledge of Respondents on Responses
IPTp
Purpose of using malaria prevention (IPTP) Frequency Percentage
drug? Y %
To make me gain weight - -
To make me and my baby strong 45 13
To prevent me from getting malaria 246 70
To give me blood 58 17
Total 349 100
Type of drug used to prevent malaria (IPTp)
Amalari 49 14.0
Fansider 192 55.0
Fersolate 76 21.8
Others 32 9.2
Who can be given malaria prevention (IPTp) drug
Men 87 25
Pregnant women 210 61.2
Non- pregnant women 52 15
Total 349 100
When is malaria prevention drugs (IPTp) given
during pregnancy
1-3months 70 20.0
4-6months 134 38.4
7-9months - -
Don’t know 145 41.6
Total 349 100
The above table reveals the component of the prevent the pregnant from getting malaria compared
knowledge of respondents on IPTp. On the to 58 (17%) and 45 (13%) respondents that gave
question, which is the IPTp used for? A total of 246 wrong reasons. On the type of drugs IPTp used, the
(70%) respondents correctly identified that it is to highest frequency shows Fansiders with

192(55.0%), followed by respondent that choose option non-pregnant women with 52(15%). On
Fersolate 76(21.8%), then Amalar 49(14.0%) while when the drugs are given during pregnancy the
the lowest is others with 32(9.2%). respondents that choose the option don’t know when
IPTp drugs is taken during pregnancy has the
In the question who can be given IPTp drugs it highest frequency 145(41.6%) followed by
shows that respondents with the highest frequency respondent with option of month range 4-6 months
choose pregnant women with 210(60.0%), followed with 134(38.4%) and the lowest option is month
by those who choose men 87(25%) and the lowest is range 1-3months with 70(20.0%).
Figure 1: Source of Information on IPTp
The figure 1 above reveals that respondents with the ANC with 117(33.5%) and lowest is information
highest source of information is from television with gotten from radio with 70(20.1%).
162(46.4%) followed by information gotten from
Table 2. Attitude of respondents toward of IPTp drugs

Reason for not taking the malaria prevention Frequency Percentage
drugs (IPTP)
The side effect is not good 30 29
It was not prescribed 34 33
Afraid of taking it 34 33
No reason for not taking it 6 5
Total 104 100
Would like to take the malaria prevention drugs (IPTp)?
Yes 233 66.8%
No 116 33.2
Total 349 100
Feel malaria prevention drugs (IPTp) will affect you baby
Yes 93 26.6
No 256 73.4
Total 349 100

The table 2 above shows component of the taking it with 6(5%). In the question on willingness
respondent attitude toward IPTp. On the of the respondents to take the drugs, the respondents
respondent’s reason for not taking the drugs, the whose choice was Yes, had the highest frequency of
highest frequency was seen among those who chose 233(66.8%), while the lowest respondents chose No
the option that the side effect is not good 30(29%), with 116(33.2%) and finally the majority of the
followed by afraid of taking it 34(33%) respectively respondents 256(73.4%) don’t feel it will affect their
while the lowest respondents has no reason for not baby.
Table 3: Utilization of IPTp by the respondents

Malaria preventive drugs ever been prescribed Frequency Percentage %
Yes 305 87.4
No 44 12.6
Total 349 100
Where the malaria preventive drugs were taken
Hospital 46 13.2
Home 199 57.0
Did not take it 104 29.8
Total 349 100
The table shows the component of utilization of On the question on where the drugs were taken,
IPTp by respondents. The first question reveals that majority of respondents 199(57.0%) took the drug at
majority of respondents 305(87.9%) were prescribed home, followed by 104(29.8%) respondents did not
with IPTp drug, while 44(12.6%) were not. take the drug prescribed while the lowest fraction
46(13.2%) respondents took the drug in the hospital.
Table 4: Factors influencing the utilization of IPTp.

Gestational period that influencing utilization of IPTp Respondents Frequency
1-2 months 60
4-6 months 203
Above 6 months 66

Figure 2: Gestational age at first visit.
The above figure shows gestational age 4-6 months gestational age at 76(21.8%) and 70(20%)
having the highest frequency of 203(58.2%) at first respectively.
visit, followed by above 6months and 1-3months of
Table 4: Socio-demographic characteristics of respondents on IPTp

Socio-demographic variables Responses in frequency Responses in percentage
Age
16-20 years 17 4.9
21-25years 70 20.1
26-30years 140 40.1
31-35years 88 25.1
Above 35years 34 9.7
Total 349 100
Educational status
Primary level 22 6.3
Secondary level 168 48.1
Tertiary level 54 15.5
Arabic 22 6.3
None 83 23.8
Total 349 100
Occupation
Civil servant 99 28.4
Trading 88 25.2
Artisan 17 4.9
Unemployment 145 41.5
Total 349 100
Gestational Age
1-3 months 182 52
4-6 months 92 26
Above 6 months 75 22
Total 294 100
The above table shows the socio-demographic variable, age group 21-25years has the highest
characteristics of the respondents. In the age number of frequency 140(40.1%), while the lowest

was seen in the age group 16-20 years 17(4.9%). Nankwanga and Gorette (2008) showed that only
The educational status of the respondents showed 21% of the intervened respondents have been told
that 160(48.1%) were educated to secondary school the drugs for use to prevent malaria and 31.5% knew
level followed by respondents with no educational the drug used in malaria prevention. A previous
status 83(23.8%). Those educated to tertiary level study by Antwi (2010) showed that 60.1% of
was 54(15.5%) while primary and Arabic was pregnant women had good knowledge of IPTp and
22(6.3%) respectively. are aware of the purpose of taking SP, while 64.5%
knew the benefit and 68.5% knew the interval that
Distribution based on the occupational status of the SP is taken.
respondents indicated that 145(41.5%) were
unemployed, 99(28.4%) were civil servant, In this study majority of the respondents 46.4% got
88(25.2%) were traders and 17(4.9%) were artisans. their information from television jingle followed by
ANC 33.5%. This finding may be due to excess
On the question regarding the gestational age, the work overload among midwives’ antenatal clinic
respondents with the highest frequency is that may be preventing effective dissemination of
respondents within the range 1-3months 182(52%) the right information on IPTp to pregnant women.
followed by 4-6months 92(26%) while the lowest Non-validated information from television may
pregnancy is above 6 months 145(1.5%). result in miss information.
Discussion On the attitude of the respondents towards IPTp this

The findings of this study indicate that the study reveals good attitude since the majority 66.8%
knowledge of pregnant women on IPTp is good would like to take the drugs and about 73.4% of the
since more than half of the respondents (70%) know respondents feels it has no side on the newborn baby
that IPTp drugs are used to prevent them from this may be because of the belief that since the
getting malaria infection. Similarly, about (50%) of treatment is prescribed by medical personnel and in
the pregnant women identified fansidar as type of a health facility, it is not likely to harm their unborn
drugs used for IPTp. This could be attributed to the baby. Pregnant women know that medical personnel
fact that fansidar is only IPTp drugs that is and hospitals are ethically bound to ensure that
prescribed for malaria prevention in the institution. prescribed therapy is beneficial and will not cause
harm. This finding is consistent with a previous
The study also revealed that the majority of the report (Onaka et al., 2012) which revealed that
respondents (60%) knew that IPTp drugs is giving to pregnant women have good attitude towards IPTp
pregnant women and in the knowledge of when since it was giving to them by health workers. Our
IPTp drugs is given, the respondents were not able finding is however contrary to a previous report
to identify when since majority of the respondents (Akinyele et al., 2009) which indicated that pregnant
(41.6%) said they don’t know when. This finding is women have poor attitude to IPTp since they believe
indicative of poor information or missed information that the drugs may cause them complications during
giving to respondents by the health practitioners. pregnancy. Similarly, Mbonye and Colleagues
This study shows good knowledge of IPTp drugs (2007) reported that pregnant women believe that SP
among pregnant women. The possible reason for is strong and weakens them and can cause abortions
this finding may be due to the fact that the hospital and foetal abnormalities.
is located in the urban area. The setting of antenatal
care in this facility is contrary to the study Utilization of IPTp in this study shows that majority
conducted by Akinyele and Colleagues (2009) of pregnant women 87.4% were prescribed of IPTp
whose study concluded that the knowledge IPTp drugs while 57.0% of the respondents took their
among pregnant women was poor (23.9%) as drugs at home, 13.2% took their drugs in the
majority did not know that SP is the recommended hospital without supervision of health worker and
drugs to pregnant women. In a related study, 29.8% respondents did not take it. Our finding is

consistent with a a previous report by Onaka and country to facilitate maximum uptake and utilization
Colleagues (2012) which indicated that 84.4% of of IPTp. Assessing the respondents attitude and
pregnant women took their drugs at home while utilization towards IPTp, it was observed that
17.6% took theirs in the hospital under supervision). majority of the respondents have good attitude but
There was low IPTp drug utilization in this study poor utilization of the IPTp drugs due to several
since those who took the drugs at home might not reasons such as side effect and fear.
have taken the right dosage. Also, many respondents Sociodemographic characteristics has no influence
may not have taken the medication because of fear towards the utilization of IPTp. Gestational age at
of potential side effects and other unfounded first visit has a positive influence.
reasons. Our finding is consistent with previous
reports (Akinyele, 2009 and Mubyazi, 2008) which Recommendations
indicated low IPTp utilization. Our finding is In view of the findings in this study the following
however at variance with report by Antwi (2010) recommendations are made:
who showed a good utilization of IPTp drugs by a. Midwives should educate the pregnant women
pregnant women. The reason for their observation on the importance of IPTp drugs to both the
may be because they practice direct observation pregnant women and the unborn babies.
therapy (DOT) in their setting. DOT may be a b. Training and retraining of Obstetricians and
feasible way to improve IPTp drug utilization Midwives through seminar and workshop so as
among pregnant women in Nigeria. to update their knowledge on WHO and Federal
Ministry of Health strategy on IPTp drug.
In assessing the factors influencing utilization of c. Clinicians during prescription should explain to
IPTp it was discovered that socio-demographic the pregnant women how IPTp and the
characteristics has no relationship in the utilization potential side effects.
of IPTp. This finding is consistent with a previous d. Pharmacist should also educate the pregnant
report (Merchant et al., 2008) in Tanzania which women on IPTp usage and side effect at the
showed no evidence of any association between point of dispensing of the therapy.
utilization of IPTp and any individual factors. Our e. Health institution should implement DOT
finding is at variance with a previous report (Ouma strategy on IPTp.
et al., 2007) which indicated that single marital f. Pregnant women should be encouraged to
status and low level of education are factors register for antenatal clinic early in their
influencing IPTp utilization. Gestational age at first pregnancy.
visit and the practice of DOT strategy can have a g. Pregnant women should be allowed to freely to
positive influence utilization of IPTp. Similarly, Pell ask questions during counselling and health
and Colleagues (2011) reported that gestational age talks on the treatment and the implication of the
at first visit has consequences of malaria. Also, a treatment.
previous report (Tarmo 2007) indicated that 40% of h. There may be need for midwives to involve the
pregnant women did not swallow their tablet at the husbands in health talk so as to enhance
clinic. utilization of IPTp during pregnancy.
Conclusion References
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n.


Review Article
SJMLS-2(1)-2017-008
Overview of Safety of Blood Transfusion
Uche, V. N.1, Ikpeama, O. J. 2*, Ogwuegbu, J.U. 3, Ikpeama, C.A. 4, Ikpeama, A. E. 5, Ikpeama, C. J. 6
Department of Public health Imo State University, Owerri 1, Brigade Medical Centre Sokoto 2, Department of
Medicine, Imo State University Owerri 3, Federal Medical Centre Kebbi State 4, Department of Anatomy,
Anambra State University, Uli 5, Médecins Sans Frontières 6.
Author for Correspondence*: ikpeama35@gmail.com/+234-806-261-9025
Abstract clotting factors cannot (Suiter et al., 2002; Allain et

A transfusion transmitted infections (TTIs) is a al., 2000 and Berkman et al., 1988).
potential pathogen (virus, bacteria or parasitic) that
can be transmitted in donated blood through a blood The first historical attempt at blood transfusion was
transfusion to a recipient. The term is usually limited described by the 15th-century chronicler Stefano
to known pathogens, but also sometimes includes Infessura. Infessura relates that, in 1492, as Pope
agents such as Simian foamy virus which are not Innocent VIII sank into a coma, the blood of three
known to cause disease. TTIs Constitute great boys was infused into the dying Pontiff (through the
public epidemic hence preventing the spread of mouth, as the concept of circulation and methods for
these diseases especially HIV by blood transfusion intravenous access did not exist at that time) at the
should be addressed in several ways. In many suggestion of a physician. The boys were ten years
cases, the blood is tested for the pathogen, old, and had been promised a ducat each. However,
sometimes with several different methodologies. not only did the pope die, but so did the three
Donors of blood are also screened for signs and
children. Some authors have discredited Infessura's
symptoms of disease and for activities that might put
account, accusing him of anti-papalism. Beginning
with Harvey's experiments with circulation of the
them at risk for infection. Being able to detect new
blood, more sophisticated research into blood
HIV infections earlier is not only beneficial to people
transfusion began in the 17th century, with
seeking testing and to the service providers offering
successful experiments in transfusion between
testing services, but may also play a significant role animals. However, successive attempts on humans
in preventing further transmission of HIV within the continued to have fatal results.
population. Lack of p24 and HIV NAT test at
different health facility at both urban and rural area The first fully documented human blood transfusion
is a great health concern in blood safety. If a local was administered by Dr. Jean-Baptiste Denys,
supply is not safe, blood may be imported from other eminent physician to King Louis XIV of France, on
areas. June 15, 1667. He transfused the blood of a sheep
into a 15-year old boy, who survived the transfusion.
Introduction Denys performed another transfusion into a laborer,
Transmission of HIV and other blood-borne viruses who also survived. Both instances were likely due to
can occur during transfusion of blood components the small amount of blood that was actually
(whole blood, packed red cells, fresh-frozen plasma, transfused into these people. This allowed them to
cryoprecipitate, and platelets) derived from the withstand the allergic reaction. Denys' third patient
blood of an infected individual (Donegan et al., to undergo a blood transfusion was Swedish Baron
1994). Depending on the production process used, Bonde. He received two transfusions. After the
blood products derived from pooled plasma can also second transfusion Bonde died. In the winter of
transmit HIV and other viruses, but recombinant 1667, Denys performed several transfusions on
Antoine Mauroy with calf's blood, who on the third

account died. Much controversy surrounded his had moved to London, where his growing practice
death. Mauroy's wife asserted Denys was soon led him to abandon research.
responsible for her husband's death. But Mauroy's
wife was accused of causing his death. Though it The science of blood transfusion dates to the first
was later determined that Mauroy actually died from decade of the 19th century, with the discovery of
arsenic poisoning. Denys' experiments with animal distinct blood types leading to the practice of mixing
blood provoked a heated controversy in France. some blood from the donor and the receiver before
Finally, in 1670 the procedure was banned. In time, the transfusion (an early form of cross-matching). In
the British Parliament and even the pope followed 1818, Dr. James Blundell, a British obstetrician,
suit. Blood transfusions fell into obscurity for the performed the first successful blood transfusion of
next 150 years. Christian Zagado examined the human blood, for the treatment of postpartum
effects of changes in blood volume on circulatory haemorrhage. He used the patient's husband as a
function and developed methods for cross- donor, and extracted four ounces of blood from his
circulatory study in animals, obviating clotting by arm to transfuse into his wife. During the years 1825
closed arteriovenous connections. His newly devised and 1830, Dr. Blundell performed 10 transfusions,
instruments eventually led to actual transfusion of five of which were beneficial, and published his
blood. results. He also invented many instruments for the
transfusion of blood. He made a substantial amount
"Many of his colleagues were present towards the of money from this endeavor, roughly $50 million
end of February 1665 he selected one dog of (about $2 million in 1827) real dollars (adjusted for
medium size, opened its jugular vein, and drew off inflation). In 1840, at St George's Hospital Medical
blood, until… its strength was nearly gone. Then, to School in London, Samuel Armstrong Lane, aided
make up for the great loss of this dog by the blood by Dr. Blundell, performed the first successful
of a second, I introduced blood from the cervical whole blood transfusion to treat haemophilia.
artery of a fairly large mastiff, which had been George Washington Crile is credited with
fastened alongside the first, until this latter animal performing the first surgery using a direct blood
showed it was overfilled by the inflowing blood." transfusion at the Cleveland Clinic. Many patients
After he "sewed up the jugular veins," the animal had died and it was not until 1901, when the
recovered "with no sign of discomfort or of Austrian Karl Landsteiner discovered human blood
displeasure." Lower had performed the first blood groups, that blood transfusions became safer.
transfusion between animals. He was then Mixing blood from two individuals can lead to
"requested by the Honorable Boyle… to acquaint blood clumping or agglutination. The clumped red
the Royal Society with the procedure for the whole cells can crack and cause toxic reactions, which can
experiment," which he did in December of 1665 in have fatal consequences. Karl Landsteiner
the Society’s Philosophical Transactions. On 15 discovered that blood clumping was an
June 1667 Denys, then a professor in Paris, carried immunological reaction which occurs when the
out the first transfusion between humans and receiver of a blood transfusion has antibodies (A, B,
claimed credit for the technique, but Lower’s both A & B, and neither) against the donor blood
priority cannot be challenged. Six months later in cells. Karl Landsteiner's work made it possible to
London, Lower performed the first human determine blood groups (A, B, AB, and O) and thus
transfusion in Britain, where he "superintended the paved the way for blood transfusions to be carried
introduction in a patient’s arm at various times of out safely. For this discovery, he was awarded the
some ounces of sheep’s blood at a meeting of the Nobel Prize in Physiology or Medicine in 1930.
Royal Society, and without any inconvenience to
him." The recipient was Arthur Coga, "the subject of Development of Blood Banking
a harmless form of insanity." Sheep’s blood was While the first transfusions had to be made directly
used because of speculation about the value of blood from donor to receiver before coagulation, in the
exchange between species; it had been suggested 1910s it was discovered that by adding anticoagulant
that blood from a gentle lamb might quiet the and refrigerating the blood it was possible to store it
tempestuous spirit of an agitated person and that the for some days, thus opening the way for blood
shy might be made outgoing by blood from more banks. The first non-direct transfusion was
sociable creatures. Lower wanted to treat Coga performed on March 27, 1914 by the Belgian doctor
several times, but his patient refused. No more Albert Hustin, who used sodium citrate as an
transfusions were performed. Shortly before, Lower anticoagulant. The first blood transfusion using
blood that had been stored and cooled was

performed on January 1, 1916. Oswald Hope blood collection in 1950. Replacing breakable glass
Robertson, a medical researcher and U.S. Army bottles with durable plastic bags allowed for the
officer, is generally credited with establishing the evolution of a collection system capable of safe and
first blood bank while serving in France during easy preparation of multiple blood components from
World War I. a single unit of whole blood. Further extending the
shelf life of stored blood was an anticoagulant
The first academic institution devoted to the science preservative, CPDA-1, introduced in 1979, which
of blood transfusion was founded by Alexander increased the blood supply and facilitated resource-
Bogdanov in Moscow in 1925. Bogdanov was sharing among blood banks.
motivated, at least in part, by a search for eternal
youth, and remarked with satisfaction on the Dangers of Blood Transfusion
improvement of his eyesight, suspension of balding, Transmission of HIV by transfusion has become rare
and other positive symptoms after receiving 11 in developed countries since the initiation of
transfusions of whole blood. In fact, following the voluntary deferral of donors at risk for HIV
death of Vladimir Lenin, Bogdanov was entrusted infection and routine HIV antibody testing of all
with the study of Lenin's brain, with a view toward donations. Continued improvement in donor
resuscitating the deceased Bolshevik leader. recruitment practices, donor education, donor
Tragically, but perhaps not unforeseeably, screening, and blood testing has resulted in
Bogdanov lost his life in 1928 as a result of one of continued decreases in the risk of transfusion
his experiments, when the blood of a student transmission of HIV. In 1995, the risk in the United
suffering from malaria and tuberculosis was given to States of HIV-1 transmission per unit transfused was
him in a transfusion. Some scholars (e.g. Loren estimated to be between 1 in 450,000 and 1 in
Graham) have speculated that his death may have 660,000 (Schreiber et al., 1996 and Lackntz et al.,
been a suicide, while others attribute it to blood type 1995). By 2003, this estimated risk had decreased to
incompatibility, which was still incompletely between 1 in 1.4 million and 1 in 1.8 million units
understood at the time. (Goodnough et al., 2003 and Busch et al., 2003).
HIV antibody tests fail to identify HIV-infected
The Modern Era blood donated by HIV-infected persons who have
Following Bogdanov's lead, the Soviet Union set up not yet seroconverted. Exclusion of donors is
a national system of blood banks in the 1930s. News voluntary. Interviews with HIV antibody-positive
of the Soviet experience traveled to America, where donors reveal that most recognize their risk but fail
in 1937 Bernard Fantus, director of therapeutics at to exclude themselves (Cleary et al., 1988), as a
the Cook County Hospital in Chicago, established result, laboratory efforts to eliminate HIV-infected
the first hospital blood bank in the United States. In donors have continued and testing has improved.
creating a hospital laboratory that preserved and Currently, HIV antibody tests detect both HIV-1 and
stored donor blood. Fantus originated the term HIV-2 and detect antibody approximately 22 days
"blood bank". Within a few years, hospital and (the "window period") after the viremic phase of
community blood banks were established across the HIV infection begins. Antigen testing for p24,
United States. In the late 1930s and early 1940s, Dr. mandated by the U.S. Food and Drug
Charles R. Drew's research led to the discovery that Administration (FDA) in 1996, shortened the
blood could be separated into blood plasma and red window period to approximately 16 days. The
blood cells, and that the plasma could be frozen nucleic acid amplification test (NAT), which detects
separately. Blood stored in this way lasted longer HIV-1 RNA in minipools (16-24 donation
and was less likely to become contaminated. samples/pool), was introduced in the United States
Another important breakthrough came in 1939-40 in 1999 and further reduces the window period of
when Karl Landsteiner, Alex Wiener, Philip Levine, potential HIV transmission to 11 days (Busch et al.,
and R.E. Stetson discovered the Rhesus blood group 2003 and Goodnough et al., 2003). As of early 2003,
system, which was found to be the cause of the three transfusion recipients are known to have
majority of transfusion reactions up to that time. become HIV infected by transfusion of HIV
Three years later, the introduction by J.F. Loutit and antibody-negative, p24 antigen-negative, and HIV
Patrick L. Mollison of acid-citrate-dextrose (ACD) NAT-negative blood from two different blood
solution, which reduces the volume of anticoagulant, donors (among 25 million donations) (CBS, 2002).
permitted transfusions of greater volumes of blood The global perspective is not as bright as that
and allowed longer term storage. Carl Walter and described for resource-rich countries. Worldwide, 75
W.P. Murphy, Jr., introduced the plastic bag for million units of blood are estimated to be donated

annually, compared with 13 million donations in the infected for similar duration but by other routes
United States. Of the 191 WHO member states, only (Donegan et al., 1986 and Giesecke ,1988). One
43% test blood for HIV, hepatitis C, and hepatitis B report found that a transfusion recipient may
viruses. Transfusion-transmitted HIV infection is develop AIDS more rapidly if the infected blood
thought to account for 80,000-160,000 infections component comes from a blood donor who develops
annually, contributing 2-4% of all cases of HIV AIDS soon after the time of the blood donation
transmission (Goodnough et al., 2003; Bharucha et (Ward et al., 1989). Other analyses, however, do not
al., 2002 and Noel,2002). Only 20% of the world's confirm this finding (Busch et al., 1990). It is more
supply of safe blood is available to countries with likely that host factors, particularly the recipient's
80% of the world's population. age and immune status, and perhaps other as-yet-
undefined cofactors influence the progression to
The risk of HIV transfusion through infected blood AIDS (Menitove, 1989 and Operskalski et al.,
products exceeds that of any other risk exposure. 1995). The mean time of progression to AIDS is
Ninety percent of recipients transfused with HIV estimated to be 8.2 years for adult transfusion
antibody-positive blood are found to be HIV recipients who receive no antiretroviral therapy,
infected at follow-up (Donengan et al.,1994). No with a cumulative prevalence of 20% having AIDS
HIV-infected but persistently seronegative 5 years after infection (Medley et al., 1987).This
transfusion recipients have been identified. The 90% progression rate may be overestimated, and the
probability of seroconversion is independent of the mean time to AIDS development underestimated,
age or gender of the recipient, the reason for because these values are based primarily on data
transfusion, and the type of component transfused from recipients identified because they developed
(excluding washed red blood cells, which transmit AIDS or because they received blood from donors
HIV at a lower rate) (Donengan et al., 1990). who subsequently developed AIDS. The data
exclude many donors and recipients who have not
HIV infectivity of red blood cell components that been identified because they remain asymptomatic.
were not washed before transfusion decreases as
storage time increases. HIV-contaminated red blood HIV Transmission from Plasma-Derived Blood
cells stored for <8 days are 96% infectious, whereas Products
those stored for >3 weeks are 50% infectious To produce plasma-derived products, plasma from
(Donegan et al., 1994). The level of a donor's 2,000 to 30,000 donors is pooled and processed into
viremia at the time of donation is also an important a single batch (lot). One HIV-infected donor can
determinant of HIV transmission risk, but no other contaminate an entire lot of product and
donor characteristics have been found to affect consequently infect each of the recipients if HIV is
transmission (Busch et al., 1996) Of all transfused not neutralized by sufficient heat, cold ethanol, or
patients, half die within 6 months after transfusion other treatments during production. A variety of
from the underlying disease that necessitated the different blood products can be manufactured by
transfusion. Currently, cases involving transfusion successive precipitation with increasing
of HIV-positive blood do not increase the overall 1- concentrations of cold ethanol. Individual fractions
year post-transfusion mortality rate of recipients in are then further processed, during which time
the United States. In Zaire, however, patients partially concentrated fractions from as many as
transfused with HIV-positive blood are 31% more 100,000 donors may be combined (Morgenlhaler et
likely to be dead 1 year after transfusion than are al., 2001).
patients transfused with HIV-negative blood
(Colebunders et al., 1991). This difference is Albumin and Immune Globulin Products
unexplained but emphasizes the importance of Albumin and plasma protein (Cohn fractions IV and
screening blood for HIV in developing countries. V) are extracted with the maximum concentration of
HIV disease due to transfusion progresses in the cold ethanol and are then pasteurized. They do not
recipient at rates comparable to those in individuals transmit HIV. Cohn fraction II products (immune

globulins such as Rh immune globulin, gamma derived concentrates does, however, result in a six-
globulin, and hepatitis B immune globulin) are fold increase in the annual cost of clotting factor
treated with somewhat lower concentrations of cold replacement (Pierce et al., 1989). Cloning of the
ethanol and cannot be pasteurized without loss of factor VIII gene in the late 1980s allowed for the
activity. Nevertheless, HIV has not been cultured development of recombinant factor products, and
from lots of Cohn fraction II products known to be preparations purified by monoclonal antibody
positive for HIV antibody. The presence of high- affinity techniques are now available. Some
titer antibody to HIV in some lots of hepatitis B haemophilia clinicians use these "ultrapure" and
immune globulin has resulted in transient (<6 "high-purity" products for factor replacement in
months' duration), low-titer antibody to HIV in HIV-infected haemophiliacs because this method
recipients and has raised questions about the safety decreases exposure to foreign antigen, which
of these products. There have been, however, no evidence suggests may hasten progression of HIV
documented cases of HIV disease as a result of their disease (Varon et al., 1994 and Berntorp et al.,
use. Over 4.5 million doses of Rh immune globulin 1994).
have been given since 1968, with no reported cases
of HIV disease in recipients. Thus, although Haemophilia and Progression to AIDS
recipients of hepatitis B immunoglobulin may The rate of progression to AIDS in HIV-positive
become transiently HIV antibody positive by haemophiliacs is directly related to age at the time of
passive acquisition of antibodies from the HIV infection. The incidence of AIDS in older adult
immunoglobulin preparation, there is no evidence haemophiliacs infected with HIV is comparable to
that these individuals are actually infected (Sugg et that of HIV-infected homosexual men and
al 1987 and Tedder et al., 1983). transfusion recipients in the same age group
(Operskalski et al., 1995 and Rosenberg et al.,
Clotting Factor Concentrates 1994). Over an 8-year period, older HIV-infected
Pooled plasma is also precipitated and processed haemophiliacs are more likely than younger HIV-
into the factor VIII concentrates used to treat infected haemophiliacs to develop AIDS (13.3% for
haemophilia A and into factor IX concentrates used ages 1-17 years, 26.8% for ages 19-34 years and
to treat haemophilia B. Before 1984, factor 43.7% for ages 35-70 years) (Operskalski et al.,
concentrates were not heat treated, because heat 1995). Severity of haemophilia and amount of factor
treatment causes a loss of haemostatic activity. As a concentrate received have not been shown to
result, HIV was not inactivated, and roughly 80% of influence the rate of progression to AIDS in HIV-
treated haemophilia A patients and 50% of treated infected haemophiliacs (Gjerset et al., 1994).
haemophilia B patients were infected with HIV-1
(Dietrich et al., 1990; Sugg et al 1987). The severity Why is it valuable to detect HIV infections as
of haemophilia, and thus the amount of factor early as possible?
concentrate received, correlated directly with the There are two major reasons why it is valuable to
probability of becoming HIV seropositive. Lower detect an HIV infection as soon as possible after it
rates of seroprevalence in haemophilia B patients has occurred:
compared to haemophilia A patients appear to be 1. Early detection is good for people getting
related to the use of higher concentrations of ethanol tested for HIV. HIV tests that provide an
in the manufacture of factor IX concentrate. Since accurate result sooner after infection may
1984, multiple methods for inactivating HIV have significantly reduce the anxiety of “not
been developed and applied (Fricke et al ., 1993). knowing” that many people feel after they think
Methods vary, but all use both heat treatment and at they may have been exposed to HIV. For those
least one other viral inactivation process. No HIV who test HIV-positive, testing early may give
antibody seroconversions have yet occurred among them a better sense of how and when they were
uninfected persons using factor products now on the exposed to HIV. It may also provide them with
market. Improved safety and purity of plasma- greater opportunities to access services and

support that will help manage their health and five to six weeks (and sometimes even earlier). A
well-being. Another distinct advantage of early positive p24 test means that someone is HIV-
diagnosis is that people can access anti-HIV positive. However, a negative p24 test can mean
treatment before their immune systems have three things:
been severely damaged, which can also  the person is HIV-negative
improve their long-term health outcomes.  the person is HIV-positive but that the test
could not detect the p24 protein because the
2. Early detection can help prevent new HIV person was infected more than four to six
infections. Research demonstrates that almost weeks earlier
half of new HIV infections may come from  the levels of p24 antigen are too low to be
individuals who have been newly infected. This detectable with current technologies.
may be because people who are newly infected
have significantly higher levels of the virus in Currently, the most advanced tests combine a p24
their blood and genital tracts, which may make antigen test and an antibody test. While combination
HIV transmission more likely to occur tests are available in some regions across Canada,
(Kannangai et al., 2008; Stekler et al., 2007; they are not yet available everywhere. These tests
Busch et al., 1997 and Kahn et al., 1991). are seen as beneficial because they combine the
People who are newly infected are also more early detection abilities of the p24 antigen test with
likely to be unaware of their HIV status. the accuracy of the newer antibody tests. It should
Diagnosing HIV infection early allows a person be noted that a rapid (point-of-care) version of these
to make more informed decisions (such as tests is not yet available.
practicing safer sex and using drugs in a safer
way). Research shows that when aware of their The HIV NAT test
status, most HIV-positive people do take steps The HIV NAT test is a very sensitive test designed
to prevent HIV transmission (Kilmarx et al., to detect HIV RNA in blood. RNA is the viral
1998; Hays et al., 1997; Wenger et al., 1994 equivalent to human DNA. The NAT test is able to
and Higgins et al., 1991). detect HIV RNA as early as seven to 14 days after
infection with HIV (Stekler et al., 2007; Fiebig et
Being able to detect new HIV infections earlier is al., 2003; Busch et al., 1997 and Sickinger et al.,
not only beneficial to people seeking testing and to 1994). Unlike the p24 test, the NAT test will always
the service providers offering testing services, but give a positive result as long as there is HIV in
may also play a significant role in preventing further someone’s blood. NAT testing is currently being
transmission of HIV within the population. The two offered in six clinics in British Columbia as part of a
most commonly used tests that detect HIV directly five-year study called the Acute HIV Infection
are the p24 antigen test and the HIV nucleic acid Study. One of the objectives of this study is to
amplification test (NAAT). investigate the impact of new testing technologies
on gay men’s testing practices.
The HIV p24 antigen test When are p24 antigen tests and HIV NAT tests
The HIV p24 antigen test, the most widely available used?
of the two, is designed to detect a protein (the p24 In places where p24 antigen tests or HIV NAT tests
protein) associated with HIV. The p24 antigen test are available, these tests are often used for
can detect the p24 protein on average 10 to 14 days individuals who have recently had a high-risk
after infection with HIV (Busch et al., 1997; Stekler exposure and are either (a) in the three-month
et al., 2007; Fiebig et al., 2003 and Sickinger et al., window period of the antibody test, or (b)
1994). One drawback of this test is that levels of the experiencing symptoms of a new HIV infection
p24 protein peak at around three to four weeks after (most often flu-like symptoms, including a fever,
exposure to HIV and are usually not detectable after diarrhoea, rash and/or sore throat). The p24 antigen

test is also used when indeterminate results are

obtained from an HIV antibody test (the test The p24 antigen test and the HIV NAT test could be
couldn’t give a clear answer). used to test for HIV in people who think they were
recently exposed to HIV. These tests are useful for
It is also important to talk about the symptoms of people who think they have recently seroconverted.
seroconversion when we talk about testing. As these tests, may not be readily available in all
Educating clients about the symptoms of cities and towns, it may be useful to find out when
seroconversion may increase the likelihood that they and where these new and improved testing
will get tested if they experience symptoms. technologies will be offered in your area.
Seroconversion symptoms can occur from two to
four weeks after infection and may include flu-like Effort at safe blood transfusion
symptoms, such as fatigue, fever, sore throat, The risk of transmission of serious infections,
swollen lymph nodes, headache, loss of appetite or including HIV and hepatitis, through unsafe blood
skin rash. This illness usually lasts less than two and chronic blood shortages brought global attention
weeks although it can last as long as 10 weeks. If a to the importance of blood safety and availability.
client has had a recent high-risk encounter and This fact sheet is based on the data obtained through
experiences any of these symptoms, they should be the WHO Global Database on Blood Safety (GDBS)
encouraged to have an HIV test. Depending on the for the year 2013 which were reported by 156
time since infection, the antibody test may not give countries. To give a more complete overview of the
an accurate result. However, if available, the p24 global situation, data for the year 2012 have been
antigen test will be able to give an accurate result used from 14 countries and data for the year 2011
two to four weeks following infection and the NAT have been used from 9 countries, where current data
test will be accurate in as little as seven to 14 days are not available. Overall, responses received from
after infection.at does all this mean for front-line 179 countries cover 98.6% of the world’s
workers? population. HIV in high-income countries 0.003%
(0.001%-0.040%), middle income countries 0.120%
The early detection of HIV is important because (0.020-0.340%) and low income 1.080% (0.560%-
people who are newly infected are very infectious 2.690%). With the goal of ensuring universal access
and may inadvertently transmit HIV to others. There to safe blood and blood products, World Health
is still a lot of misunderstanding about how soon one Organization (WHO) has been at the forefront to
should get tested after potential HIV exposure. improve blood safety and availability, and
Many people still believe they have to wait three recommends the following integrated strategy for
months. However, new and improved testing blood safety and availability:
technologies are continually decreasing the amount  Establishment of a national blood system with
of time it takes for a new HIV infection to be well-organized and coordinated blood
detected. transfusion services, effective evidence-based
and ethical national blood policies, and
In the case of clients at high risk of HIV, testing can legislation and regulation, that can provide
be done as early as one month after exposure for sufficient and timely supplies of safe blood and
standard antibody assays and rapid point-of-care blood products to meet the transfusion needs of
tests. Clients who test positive will know for certain all patients.
they are HIV-positive. Of those who test negative,  Collection of blood, plasma and other blood
95% are in fact negative. It is important to realize components from low-risk, regular, voluntary
that up to 5% of people who test negative at one unpaid donors through the strengthening of
month could later test positive at three months. It is donation systems, and effective donor
important to ensure that people testing negative at management, including care and counselling.
one month are advised to return for repeat testing
once the three-month window period is covered.

 Quality-assured screening of all donated blood  The length of the window period varies
for transfusion-transmissible infections (TTIs), between individuals; UK guidelines state
including HIV, hepatitis B, hepatitis C and that for a fourth-generation test the window
syphilis, confirmatory testing of the results of period is one month.
all donors’ screening-reactive for infection  Testing during this period can result in false
markers, blood grouping and compatibility negative results.
testing, and systems for processing blood into  People seeking testing may be confused or
blood products (blood components for uncertain about the significance and length
transfusion and plasma derived-medicinal of window periods.
products), as appropriate, to meet health care
needs. The window period refers to the time after infection
 Rational use of blood and blood products to and before seroconversion, during which markers of
reduce unnecessary transfusions and minimize infection (HIV-specific antigen and antibodies) are
the risks associated with transfusion, the use of still absent or too scarce to be detectable. Standard
alternatives to transfusion, where possible, and screening tests cannot reliably detect HIV infection
safe and good clinical transfusion practices, until after the window period has passed.
including patient blood management.
 Step-wise implementation of effective quality Testing guidelines therefore recommend that a
systems, including quality management, person who may have been recently infected should
standards, good manufacturing practices, have a repeat test some weeks or months after the
documentation, training of all staff, and quality possible date of infection. But as there is a natural
assessment. variation in the time it takes different individuals to
produce detectable antigen and antibodies, definitive
Through its Blood and Transfusion Safety statements about the length of window periods are
programme, WHO supports countries in developing difficult to make. Older recommendations were to
national blood systems to ensure timely access to defer testing until as much as three months after
safe and sufficient supplies of blood and blood exposure (Stekler, 2009). However, the effective
products and good transfusion practices to meet the window period has grown shorter with more
patients’ needs. The programme provides policy sensitive, newer-generation assays. Current UK
guidance and technical assistance to countries for testing guidelines (BHIVA, BASHH and BIS 2008,
ensuring universal access to safe blood and blood BASHH ,2010), states that the time between
products and work towards self-sufficiency in safe infection and testing positive is typically one month.
blood and blood products based on voluntary unpaid Many sources agree that, in many cases, the
blood donation to achieve universal health coverage. effective window period is probably shorter still: as
In Nigeria, the blood transfusion safety is left to the little as one to three weeks. However, messages
WHO funding with the Federal, State and Local around window periods may not always reflect these
Government paying lip service. The only functional newer realities, and may not be consistent or clearly
safe blood service is at state capital only leaving the communicated. Some experts have expressed
rural and the private sector health facility at the concerns that people may unnecessarily defer or
mercy of the populace without the international avoid testing due to concerns or confusion about the
approve standard for blood safety. window period (Brenner, 2007 and Malarelli, 2007).
Factor that affect HIV transmission via blood The window period also depends on the type of
transfusion. assay used, which may also add some confusion: the
HIV test technique and Window periods figures stated here refer to the fourth-generation,
 The window period is the time during which antibody/antigen assays in standard use, while
markers of infection are not detectable. community-based, point-of-care tests used outside
the medical clinic setting still have a suggested

window period of twelve weeks). While testing calculate the number of days before which other
during the window period should not necessarily be assays are reactive. It is therefore possible to say
discouraged, it should be made clear that a negative HIV RNA becomes detectable approximately eleven
result is not necessarily reliable, and that the person days before antibodies (or that use of an HIV RNA
should return to the clinic to be retested (Hughes, test reduces the window period by eleven days). It is
2008; Wawer, 2005 and Yerly, 2008). The British more challenging to say how many days after
Association for Sexual Health and HIV issued a exposure HIV RNA is detectable, or what the total
statement on window periods in 2010, noting that length of the window period is. One way of
fourth-generation tests will detect the great majority calculating window periods therefore uses the first
of individuals who have been infected with HIV detection of HIV RNA as day zero (Fiebig, 2003).
four weeks after exposure.
 First detection of p24 approximately five
Moreover, patients attending for HIV testing who days later (typical range three to eight days).
identify a specific risk occurring more than 4 weeks  First detection of antibodies approximately
previously, should not be made to wait 3 months (12 ten days after detection of RNA (typical
weeks) before HIV testing. They should be offered a range seven to thirteen days).
4th generation laboratory HIV test and advised that
a negative result at 4 weeks’ post exposure is very Nonetheless, there is also a gap between exposure
reassuring / highly likely to exclude HIV infection. and the first detection of HIV RNA. This is
An additional HIV test should be offered to all sometimes referred to as the eclipse phase, and
persons at 3 months (12 weeks) to definitively refers to the time during which there is viral
exclude HIV infection. Patients at lower risk may replication principally at the site of infection, before
opt to wait until 3 months to avoid the need for HIV widespread dissemination of virus in the body (as
testing twice (BASHH ,2010). observed in animal models). This time period has
been thought by some to vary between four and
Calculating window periods eleven days (Kahn, 1998 and Cohen, 2010) or by
Precise figures for the duration of the window others to be between one and two weeks, but
period are difficult to come by, for a number of occasionally longer (Busch 1997 and Coombs
reasons: 2008).
 There are individual variations in its
duration. Based on the assumption that HIV RNA is first
 People infrequently present to healthcare detected approximately ten days after exposure
and have multiple plasma samples taken (Cohen, 2010). Researchers have estimated the
during this period, making this a difficult window periods to be as follows.
topic to investigate.
 A single, precise date of exposure is rarely  First detection of HIV RNA:
known. approximately ten days after exposure
(typical range 7 to 21 days).
To be calculated accurately, researchers would have  First detection of p24: approximately 17
to know the precise date that a person was exposed days after exposure (typical range 13 to 28
to HIV, and then have multiple plasma samples to days).
test with different assays (for RNA, antigen or  First detection of antibodies: approximately
antibodies). From these results, it would be possible 22 days after exposure (typical range 18 to
to give an average number of days during which 34 days).
tests were not able to detect the infection.
However, these are averages, and if the period
It is more common to be able to identify the first between exposure and detectable viraemia is as
date on which HIV RNA was detectable, and then to

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Identification and characterization of an HIV-2


Original Research
SJMLS-2(1)-2017-009
Prevalence of Rifampicin Mono Resistant Mycobacterium tuberculosis
among patients Attending Federal Medical Centre, Katsina, Nigeria.
Saddiq, M.,1* Kankara, A. S. 1, Dutsin-ma, U. A. 2
Medical Microbiology Unit, Department of Laboratory Services, Federal Medical Centre, Katsina 1,
Department of Microbiology, Bayero University, Kano 2.
*
Corresponding Author: mustaphasaddiq@gmail.com/ mustyfantastic77@yahoo.com/+234-806-720-5524
Abstract Keywords: Tuberculosis, Rifampicin Resistance,

Tuberculosis is a chronic communicable disease Human Immunodeficiency Virus (HIV), Katsina
caused by Mycobacterium tuberculosis. In recent State.
years, the control of Tuberculosis has been impeded
by the emergence of drug-resistant Mycobacterium Introduction
tuberculosis. Most Rifampicin resistant isolates of Tuberculosis (TB) is a chronic communicable
the Mycobacterium tuberculosis were also isoniazid disease caused by Mycobacterium tuberculosis
drug resistant, and hence Rifampicin resistance is
(MTB). Mycobacterium tuberculosis is a slow-
frequently used as a proxy for multidrug-resistant
tuberculosis. The aim of this research was to growing bacterium, resistant to most conventional
determine the prevalence of Rifampicin mono antimicrobial agents partly due to its impermeable
resistant Mycobacterium tuberculosis among cell wall. It may persist in a dormant or latent form,
patients attending Federal Medical Centre, Katsina. unsusceptible to agents targeting growing bacteria
st
Clinical samples processed between 1 January and (Murray, 2000).
st
31 December 2015 was included in this
retrospective study. The records of the sputum An estimated two (2) billion people worldwide are
samples processed by GeneXpert analyzer were infected with Mycobacterium tuberculosis, more
collected; data generated was then cleaned, edited, commonly known as tuberculosis, or TB. Despite
coded and afterwards exported to SPSS version 16,
major successes in reducing global TB prevalence
where descriptive statistics was performed. Of the
730 patients enrolled, males comprised 440 (60.3%) and mortality rates, TB is the single greatest
while female comprised 39.7%. The overall infectious disease killer globally, surpassing HIV
prevalence of the Rifampicin Resistant and AIDS. In 2014, 1.5 million people died from
Mycobacterium tuberculosis in this study was 11 TB, including about 400,000 who also had HIV. TB
(1.5%) while 146 (20%) of the study subjects were is however preventable, diagnosable, and curable
HIV positive. Similarly, of the 196 (26.8%) sputum (Murray, 2000).
positive samples, 11 (5.6%) were discovered to be
Rifampicin resistant of which males were found to Epidemiologically, African countries have not been
be 6 (54.5%) while all the 11 (100%) Rifampicin faring well in the rate of spread of the infection
resistant Mycobacterium tuberculosis was
since late 1980s and this has coincided with the HIV
discovered to be HIV negative. This study has
established that there is presence of Rifampicin pandemic. Co-infection of people living with HIV
Resistant Mycobacterium tuberculosis in Katsina with Mycobacterium tuberculosis has been shown to
State, Nigeria (5.6%) and all of them were observed increase the mortality rate in sub-Saharan African
among HIV negative patients (100%). We countries like South Africa, Botswana, and Zambia
recommend that there should be increase in the (Bello et al., 2014). Nigeria was ranked fifth as high
index of suspicion for early diagnosis regardless of burden country with tuberculosis according to WHO
the patient’s HIV status to control dissemination of report of 2008 (WHO, 2008). It is estimated that
the disease among the community. one-third of the world’s population is infected with

M. tuberculosis complex with around 9 to 10 million Justification

new cases reported annually (Mitchison, 1986). There are scientific publications in different parts of
Nigeria on drug resistant Mycobacterium
Rifampicin is one of the most important anti-
tuberculosis, but none have been reported in Katsina
tuberculosis (anti-TB) antibiotics (Sandman, 1999).
It inhibits bacterial DNA-dependent RNA synthesis State despite its occurrence within the population.
by inhibiting bacterial DNA-dependent RNA Therefore, this present study was carried out to
polymerase (Campbel et al., 2001). Crystal structure establish the prevalence of Rifampicin resistant
data and biochemical data indicate that Rifampicin profiles among the patients that attended Medical
binds to RNA polymerase at a site adjacent to the Microbiology Unit, Laboratory Department, Federal
RNA polymerase active center and blocks RNA Medical Centre, Katsina State from 1st January to
synthesis by physically blocking the formation of
31st December, 2015.
the phosphodiester bond in the RNA backbone,
preventing extension of RNA products beyond a
length of 2-3 nucleotides ("steric-occlusion" Aim
mechanism) (Fekhstove et al., 2008). Rifampicin has To determine the prevalence of rifampicin mono
proven to be an effective anti-tuberculosis agent and resistant Mycobacterium tuberculosis among
its use has greatly shortened the duration of patients attending Federal Medical Centre, Katsina.
chemotherapy for treatment of TB.
Specific Objectives
In recent years, the control of TB has been impeded 1. To determine HIV/Tuberculosis co-
by the emergence of drug-resistant Mycobacterium infection among the study subjects.
tuberculosis. The problem of TB has been 2. To determine Rifampicin resistance among
compounded by the emergence of multi-drug Tuberculosis positive subjects.
resistance M. tuberculosis and Human
Immunodeficiency Virus (HIV). Materials and Method
Study Area
Resistance to Rifampicin arises from mutations that Federal Medical Centre, Katsina was built by the
alter residues of the Rifampicin binding site on RNA State Government to serve as a Specialist Hospital.
polymerase, resulting in decreased affinity for However, following the Federal Government's
Rifampicin. More than 96% of the Rifampin- policy to establish a Tertiary Health Institution in
resistant strains contain a mutation in their 81 base each state, the State Government released the
point region of their RNA polymerase (rpo ß), thus structure and vast land of 546.182 acres to the
facilitating a straightforward approach to detecting Federal Government for the purpose in 1996.
Rifampicin resistance and/or mono drug resistance Clinical activities started in 1998. The main
rapidly (Mitchison, 1986). functions of the Centre are medical care, training
and research. The Center is located at Murtala
Rifampicin mono resistant TB (RMR-TB) has been Muhammad Way, Jibia Bypass, Katsina, Nigeria.
noted as a problem in the United States, particularly
in TB-HIV (human immunodeficiency virus) co- The center being situated in Katsina town, is serving
infected individuals. Most (>90%) Rifampicin mainly the whole people of Katsina State
resistant isolates were also isoniazid resistant, and comprising of 34 local governments with a
hence Rifampicin resistance is frequently used as a population of 6,483,429 people as at 2006.
proxy for multidrug-resistant TB (MDR-TB)
(Mitchison, 1986). Rifampicin resistant herald’s The hospital is equipped with Gene Xpert machine
higher rates of treatment failure and death for the that is used to determine Rifampicin mono resistant
patient and a poor outcome if the isolate is also Mycobacterium tuberculosis which is stationed in
resistant to isoniazid. Efficacy of rifampicin the Medical Microbiology Unit of the hospital
chemotherapy can be markedly reduced when laboratory department.
infections are caused by Mycobacterium
tuberculosis strains that are Rifampin resistant Data processing
(Sandman, 1999). The records of the sputum samples processed by
GeneXpert analyzer were collected from the
Medical Laboratory Unit of the Federal Medical
Centre, Katsina. Data generated was then cleaned,

edited, coded and afterwards exported to SPSS (1.5%). On their HIV status, 146 (20%) of the study
version 16, where descriptive statistics was subjects were HIV positive and the remaining 581
performed to determine the prevalence of (79.6%) and 3 (0.4%) are negative and unknown
Rifampicin resistant Mycobacterium tuberculosis status respectively.
and compared the prevalence to sex and HIV status
of the patients. The overall occurrence of the Mycobacterium
tuberculosis in this study was 196 (26.8%) with
Ethical Approval males having 142 (72.4%) and females 54 (27.6%)
The Ethics and Research Committee of the Federal (Table 2) while those with HIV were 28 (14.3%).
Medical Centre approved the study.
Similarly, of the 196 (26.8%) sputum positive
Result samples processed by GeneXpert, 11 (5.6%) were
Under this study, the record of a total number of 730 discovered to be while of the 11 Rifampicin resistant
patients that attended the facility from 1st January to Mycobacterium tuberculosis patients, males were
31st December, 2015 were retrospectively studied. found to be 6 (54.5%), slightly more than the
Among these, males comprised 440 (60.3%), females (Table: 3). However, all the 11 (100%)
slightly dominating the females. Table 1 shows the Rifampicin resistant Mycobacterium tuberculosis
overall prevalence of the Rifampicin Resistant was discovered to be HIV negative (Table 4).
Mycobacterium tuberculosis in this study was 11
Table: 1: Overall prevalence of the Rifampicin Resistant Mycobacterium tuberculosis

MTB/Rif Result
HIV Status MTB+/Rif- MTB+/Rif+ MTB-/Rif- Total
Positive 28 (3.8%) 0 (0%) 118 (16.2%) 146(20%)
Negative 155 (21.2%) 11(1.5%) 415 (56.9%) 581(79.6%)
Unknown 2 (0.3%) 0 (0%) 1 (0.1%) 3(0.4%)
Total 185 (25.3%) 11 (1.5%) 534 (73.2%) 730 (100%)
Table: 2: Prevalence of Mycobacterium tuberculosis based on gender

MTB/Rif Result
Gender MTB+/Rif- MTB+/Rif+ MTB-/Rif- Total
Male 136 (18.6%) 6 (0.9%) 298 (40.8%) 440(60.3%)
Female 49 (6.7%) 5 (0.7%) 236 (32.3%) 290(39.7%)
Total 185 (25.3%) 11 (1.5%) 534 (73.2%) 730 (100%)
Table: 3: Prevalence of Rifampicin Resistant Mycobacterium tuberculosis based on Gender

Gender MTB+/Rif+
Male 6 (54.5%)
Female 3 (45.5%)
Total 11 (100%)

Table: 4: Distribution of Rifampicin Resistant Mycobacterium tuberculosis based on HIV Status

HIV Status MTB+/Rif+
Positive 0 (100%)
Negative 11 (100%)
Unknown 0 (0%)
Total 11 (100%)
Discussion 2.5 % and 1.7% (Seyoun et al., 2014 and Sandgren

Multidrug-resistant (MDR) tuberculosis has become et al., 2012). RMR reported from America, Western
a major public health problem and presents new Pacific region and Europe were 2.1%, 4.9% and
barriers to the control of TB. It is due to human error 12% respectively (Berhe et al., 2013). The lower
as a result of poor supply management and quality prevalence observed in developed countries may
of anti-TB drugs and inadequate or improper possibly be due to unorganized patient diagnosis,
treatment as well as non-compliance. This is further treatment and follow-up. Poor patient adherence to
exacerbated by human immunodeficiency virus therapy may contribute to the higher prevalence of
(HIV). Based on WHO recommendation, RMR strains observed in this study and other studies
Rifampicin resistance is considered as surrogate in Nigeria and other developing countries.
marker for MDR tuberculosis. Therefore, we have
determined the prevalence of Rifampicin mono We observed a higher male gender predisposition to
resistant Mycobacterium tuberculosis among tuberculosis. This finding is consistent with a
suspected study subject and the findings were previous report conducted in Northern Ethiopia
associated with age and gender (Sandgren et al., (Calvori et al., 1965). This study further describes
2012). for the first time a high prevalence of Rifampicin
mono resistant Mycobacterium tuberculosis among
In vitro resistance to anti-TB drugs was first HIV negative patients.
reported in Nigeria over three decades ago and local
health practitioners have the perception that drug Conclusion
resistance has increased in the recent years. This This study has helped to establish that there is
might be due to decline in funding and interest in presence of Rifampicin Resistant Mycobacterium
tuberculosis control programs (Mitchison, 1986). In tuberculosis in Katsina state, Nigeria (5.6%) and all
2010, Rifampicin Mono-Resistant (RMR) cases of Rifampicin Resistant were observed among
tuberculosis accounted for 0.3%, 0.3%, and 0.1% of HIV negative patients (100%). This is particularly
primary TB cases, and 1.9%, 0%, and 0.2% of important for TB control agencies to note. Also,
secondary TB cases in Germany, United Kingdom, while we established less prevalence of Rifampicin
and Poland, respectively (Lawson et al., 2010). Resistant Mycobacterium tuberculosis than many
part of Nigeria, there is still room for improvement
The prevalence of RMR in this study was 5.6%%. as researches in Ethiopia, East Africa, U.S.A and
This result is lower than the finding in Abuja, North Western Pacific region all discovered less
central part of Nigeria which indicated a 19.0% prevalence.
Rifampicin monoresistance (Nwadioha et al., 2014).
Other studies conducted in different parts of Nigeria Recommendation
reported a RMR of 11.8 to 22% therefore; our We recommend that there should be enhanced
finding is lower than many other findings in other efforts in detection of Rifampicin Resistant
parts of Nigeria (Nigus et al., 2014; Akaninyene et Mycobacterium tuberculosis in the study area so as
al., 2013 and Dinic, 2012). This may reflect the to increase the index of suspicion for early diagnosis
variations in sample size, the population of the regardless of the patients’ HIV status to control
studied area, access to health care facilities, time of dissemination of the disease among the community.
the study, geography and effectiveness of TB
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Original Research
SJMLS-2(1)-2017-010
Preference of Intra Uterine Contraceptive Device (IUCD) over other
Family Planning methods among Women of child bearing age in
Owerri North L.G.A of Imo State.
Iwumune Ugochi Ijeoma 1, Ozim S.J. 2, Ikpeama O.J 3*
Department of Public Health Imo State University 08037748356 1, Department of Public Health Imo State
University 2, Department of Public Health Imo State University, Owerri 3
Author for Correspondence*: ikpeama35@gmail.com/+234-806-261-9025
Abstract device and religious leaders should be targeted for

The aim of this study was to ascertain the more education on the benefits of contraceptives as
preference of intra uterine contraceptive device a result of the very strong role they play in the
(IUCD) over other family planning methods among decision on contraceptive use among their church
women of child bearing age in Owerri North Local members.
Government Area (L.G.A) of Imo state Nigeria.
Twelve objectives, twelve research questions and Keywords: Intra Uterine Contraceptive Device,
one null hypothesis guided the study. The research Family Planning, Women, Owerri North, Imo State,
design adopted for this study was qualitative form of Nigeria.
descriptive survey design. The sample consisted of
Two Hundred (200) women of child bearing age Introduction
from five randomly selected communities in Owerri Background of the study
North L.G.A. Face and content validity of instrument Intra uterine contraceptive is a device made of
was ensured through constructive criticism by the
plastic and copper that is inserted into the womb
project supervisor and three other lecturers of the
department. Reliability of the instrument was (uterus) by way of the vaginal canal to prevent
established using Cronbach alpha of 0.82. Data pregnancy. It is widely used all over the world as a
collected was analyzed using inferential percentage. family planning method, and is considered to be
The result revealed that the subjects widely 98% effective.
preferred the use of IUCD as a method of family
planning to help them in child spacing or limiting Family planning can be defined as a means by which
child birth. It was observed from the study that 90% a couple place the process of conception,
were involved in family planning and 55% among pregnancies and childbirth at intervals mutually
them accepted the use of IUCD. Furthermore, it was determined by both husband and wife in order to
identified that husband dominance in not having
have the desire number of children that they can
more number of children was a factor that militated
against the use of IUCD in this study. It was conveniently maintain (Delamo, 2013). The World
identified that 45% of the respondents have Health Organization (WHO, 2013) defined family
increased knowledge on the use of IUCD. On the planning as a way of thinking and living that is
basis of this findings, we recommend that adopted voluntarily upon the basis of knowledge and
awareness on IUCD among women of child bearing responsible decision by individuals and couples in
age be intensified to limit the number of births, order to promote the health and welfare of family
health workers should trained to sensitize and and thus contribute effectively to social
counsel women on the knowledge and the use of development in the country. Family planning is
IUCD safety, government and non-governmental aimed at encouragement of child spacing, assist
organizations (NGOs) should provide more
couples who have fertility difficulty to achieve
educational opportunities in the rural areas for the
purpose of teaching birth control methods, pregnancy, and most importantly, prevent sexually
especially, the use of intrauterine contraceptive

transmitted disease (STD) and unwanted Statement of the problem

pregnancies. Factors including contraceptive method choices and
continuation patterns contribute to the lack of
Unexpected or unplanned pregnancy poses a major progress in reducing unintended pregnancies,
public health challenge in women of reproductive combine oral contraceptives and condom, the
age, especially in developing countries. It has been predominant reversible method used are user
estimated that the 210 million pregnancies that occur dependent, have relatively low continuation rate and
annually worldwide, about 80 million (38%) are have relatively high failure rate with typical used
unplanned and 46 million (22%) end in abortion. patterns, also the predicted effect of emergency
contraceptive to reduce unintended pregnancy has
More than 200 million women in developing not been achieved.
countries would like to delay next pregnancy or
even stop bearing children together, but many of Intrauterine contraception is gradually well
them still rely on traditional and less effective tolerated, but side effects and complications
methods of contraception or use no method at all. sometimes occur. Individuals considering use of the
Those who do not use any contraceptive method IUCD will be influenced by their own familiarity
may lack access or face barriers to using with contraception in general, by the adoption of
contraception. These barriers include lack of family planning in their social-cultural and religious
awareness, lack of access, cultural factors, religion community and by their wish to space or limit
opposition to use by partners or family member, and childbearing. A woman’s attitudes to IUCD will also
fear of health risk and side effects of contraceptives. be shaped by her knowledge of the method, her
assessment of the relative risk and benefits
The intra-uterine contraceptive device is made of associated with its use. In some cases,
two types; one type releases a hormone misinformation may dominate, fuelled by report of
(progesterone) and is replaced each year. The severe complications. The adoption of a
second type made up of copper and can be left in- contraceptive method is usually inferred from its
situ (place) for five years. The most common shape uptake (prevalence of use) and from continuation
in current use is a plastic “T” which is wrapped with rates. The above problems aroused the interest of the
copper wire known as copper “T”. researcher to proffer solution in overcoming this
shortcoming in the use of intrauterine devices.
The intrauterine contraceptive device is inserted and
removed easily at the clinic. The commonest change Objectives of the study
associated with the use of the IUCD may be the 1. To determine the level of preference of IUCD
change in women menstrual cycle. IUCD are placed over other family planning methods among
in the uterus by trained family providers women of child bearing age.
(Physician/Nurse midwife), prior to the placement,
2. To determine the most widely used family
the provider will take the medical history, do
physical examination and take a pap test. It is planning methods.
important to note that women who have had tubal 3. To determine the influence of marital status on
pregnancies and an abnormal pap smear or abnormal the preferred family planning method.
vaginal bleeding are generally disqualified from 4. To determine the influence of parity status on
using this form of contraceptive. Also, women who the preferred family planning method.
have STDs, an allergy to copper, severe pain with 5. To determine who decides whether family
periods (menstruation), sex with multiple partners or
planning should be used.
who are currently pregnant are not eligible for an
IUCD. It should be noted that IUCDs offer no 6. To determine if fear of side effects prevent
protection against acquired immune deficiency women of child bearing age from using IUCD.
syndrome (AIDs) or human immune virus or other 7. To determine the main reason that will make a
STDs. intrauterine contraceptive device is one of the woman not to used IUCD method at anytime in
fastest and the most effective contraceptive available the future.
today. It is considered” top tier contraceptive” 8. To determine if women feel safe when they use
because it ranks alongside implants and sterilization
intrauterine device.
in effectiveness and the commonest utilized
contraceptive method used in many hospitals in 9. To determine if creating awareness increases
Nigeria (Ozumba and Ibekwe, 2001). the preference of IUCD by women.

10. To determine the overall rating of the preferred Question 3: What is the influence of marital status
IUCD. on the preference of IUCD as a family planning
11. To determine if creation of awareness increases method?
Question 4: What is the influence of parity on the
the acceptability of IUCD by women.
preference of IUCD?
12. To determine the rating of the overall Question 5: What is the most widely used family
preference of IUCD. planning method?
Question 6: Whose decision is the number of
Specific objectives children wanted based on?
i. To assess awareness and interest in IUCD Question 7: Who decides whether family planning
among the women of child bearing age. should be used?
ii. To assess the determining factors leading to the Question 8: Does fear of side effects prevent women
preference of IUCD over other family methods. of child bearing age from IUCD?
Question 9: Are the women ever told what to do if
Significance of the study any side effect arises.
1. This research will help women to prevent Question 10: Do women feel safe when they use
unplanned pregnancy through appropriate IUCD
family planning. Question 11: Will creating awareness increase the
preference of IUCD by women.
2. It will help mothers to limit number of children
Question 12: What is the rating of the overall
and equally space child bearing. preference of IUCD?
3. The study brings out the interest of child
bearing women on the use of intrauterine Research Design
contraceptives, its effectiveness and Research design as explained by Creswell (2003)
reversibility refers to a methodology and procedure employed to
4. The research will increase the adoption and conduct scientific research. The design of a study
defines the study type (descriptive, correlation,
continuation of contraceptives as a means of semi-experimental, experimental, review and met
family planning thus reducing overpopulation analytic) and sub-type (e.g descriptive-longitudinal
and malnutrition. case study), research question, hypothesis,
independent and dependent variables, experimental
Scope of the study design, and if applicable, data collection methods
This study was delimited to women of child bearing and a statistical analysis plan.
age who use intrauterine contraceptive device as a The researcher used the qualitative descriptive
method of family planning in five communities in research design because the study does not involve
Owerri North Local Government Area. manipulation of numerical data; rather it involves
the use of intrauterine contraceptive device among
Research hypothesis women of children bearing age in Owerri North. In
1. There is no significant benefit in the use of order to get an accurate description of an area of
IUCD by women of child bearing age. interest, and to provide detail information about the
2. There is significant benefit in the use of existing phenomenon, the researcher used a
intrauterine contraceptive by women of child descriptive research design method which is a type
bearing age. of qualitative research design.
Research Question Target Population

The following research questions have to be Population in research means a group of people
answered in order to solve the problem noted in this from which the researcher selects or draws the
research: sample for study. It could be homogenous
Question 1: Do women of child bearing age prefer population (population that has similar
IUCD over other family methods and what is the characteristics) or heterogeneous (one that has
level of preference. dissimilar characteristics). The researcher used a
Question 2: What is the main reason that will make homogenous population for the study and this
one not to use IUCD method at anytime in the involved woman of child bearing in Owerri North.
future?

Sample and Sampling Technique Where: F = is frequency of respondents in a

A sample is a smaller portion of the population particular item
drawn for a study. It is a group selected from the N = AREA the total number of respondents
accessible population for the purpose of the study
with view to make generalization about the Area of Study/Setting
population as a whole. Random sampling technique Owerri North is a Local Government Area of Imo
was used. The subject included women of child state in Nigeria. Its headquarters is located at Uratta
bearing age who will be representatives of the in Ihitaoha autonomous community. It has an area of
population. 198 square km and a population of 175,395 at the
2006 census. Owerri North is a semi-urban local
Instrument for Data Collection/Data Collection government area. It encircles Owerri municipal like
The instrument used is questionnaire. A a peninsular. The six major roads that lead to the
questionnaire is the commonest instrument used by municipal, each cut across Owerri North
the researcher in eliciting responses from the communities. In the North, Orlu road lead to
subjects. The researcher developed a structured Amakohia and Akwakuma communities. In the East,
questionnaire on preference of intrauterine devices Okigwe road lead to Orji community. In the west,
over other family planning choices among women of MCC by Wetheral road leads to Uratta and Ihitaoha
child bearing age. This method was preferred communities. In the South, Mbaise road leads to
because it elicits vital information from the Egbu Emekuku, Emi, Awaka and Azaraubo
respondents. In this research study, the researcher communities. The transitional chairman of Owerri
used random samplings where women of child North L.G.A is Lady Ndidi Iheme. This research
bearing age where picked randomly from the study was undertaken in five (5) randomly selected
population. A total of two hundred (200) copies of communities in the L.G.A namely: Naze, Emekuku,
the questionnaire where administered to the Akwakuma, Emii and Orji.
respondents. The questionnaire was grouped in two
sections: A- which is respondents’ personal data Ethical Consideration
identification and B- which contains the major Ethical consideration as seen in questionnaire has to
questions relating to the problems of the study. do with putting into consideration the integrity of
There was a good return of the administered the respondents. Prior to administering the
questionnaires. The researcher personally questionnaire, the respondents were greeted and
administered and collected them. addressed politely and the coverage letter was show
to them, so that they may understand the value of the
Validation of Instrument research before they decide whether or not to
Validity is a concept that measures or describes participate. The researcher noticed the attitude of the
what it is supposed to measure or describe. It is respondents and assured them that all the
important for diagnostic research to ensure the information given will be treated with almost
qualitative nature of the instrument. It should confidentiality and their image will be protected
validate for it to valid. In the light of the above, the from harm and the public as they were also
researchers developed a draft copy of the instructed not to include their names.
questionnaire. Validation of the instrument was
made as the items were subjected to criticism and The following analysis was made based on the data
modification of instrument. The result obtained collected. The information was reported in tables,
showed that the items in the questionnaire were and scores were converted to percentages. A total of
valid and could be relied upon. 200 respondents were used and their responses were
analyzed.
Method of Data Analysis
Data analysis is the process by which the researcher
summarized and describe the collected data, and
make inference for the study sample where possible.
The analysis of data was based on the returned
questionnaire. In analyzing the data, all answers
were treated accordingly. The data are collected and
the score are convert to percentage. This is
expressed in a simple percentage:

Table 4.1: Marital Status of Respondents

Marital Status Number of Respondent Percentage
Single 20 10
Married 145 2.5
Divorced 15 7.5
Widowed 20 10
Total 200 100
Analysis of table 4.1 shows the marital status of married, 15(7.5%) were divorced and 20(10%) were
respondents 20(10%) were single, 145(72.5%) were widowed.
Table 4.2: Age Distribution of Respondents

Age Number of Respondents Percentage
20 – 25 20
26 – 30 14 7
31 – 35 46 23
36 – 40 100 50
> 41 20 10
Total 200 100
Table 4.2 shows that 20(10%) of respondents were between the ages of 31 – 35, 100(50%) were
between the ages of 20 – 25 years, 14(7%) were between 36 – 40 years and 20(10%) were greater
between the ages of 26 – 30 years, 46(23%) were than 41 years.
Table 4.3: Occupations of Respondents

Occupation Number of respondents Percentage
Civil servant 3 1.5
Farmer 30 15
Trader 45 22.5
House wife 120 60
Student 2 1
Total 200 100
Table 4.3 shows the occupation of the respondents were house wives, 30(15%) were farmers, 2 (1%)
indicating 3(1.5%) were civil servants, 120 (60%) were student and 45 (22.5%) were traders.
Table 4.3: Occupational Distribution of the Subjects

Educational level Number of respondents Percentage
Non-formal education 20 10
Primary education 80 40
Secondary education 90 45
Tertiary education 10 5
Total 200 100
Table 4.4 shows the educational level of education,90 (45%) have secondary education and
respondents. Among the subjects (20%) have no 10 (5%) have tertiary education.
formal education,80 (40%) have primary
Research Questions
Question 1: Do women of child bearing age accept intrauterine contraceptive device over other family
planning methods, and what is the level of preference?

Table 4.5: Respondents acceptance level on Intrauterine Contraceptive Device

Acceptance Number of respondents Percentage
Yes 180 90
No 20 10
Total 200 100
Table 4.5 revealed that 180 (90%) of respondents 20 (10%) did not prefer IUCD as family planning
accepted IUCD as family planning method, whereas method.
Question 2: What is the main reason that will make one not to use IUCD method at any time in future?
Table 4.6: Views of Respondents on the reason for not using IUCD in future
Responses Number of respondents Percentage
Husband opposed 50 25
Religion prohibition 10 5
Fear of side effect 100 50
Cost too much 20 10
Inconvenience to use 10 5
Interference with normal 10 5
Total 200 100
Table 4.6 revealed that 50 (25%) confirmed that that it cost too much, while 10 (5%) respectively
their husband opposed the use of IUCD, 10 (5%) said inconvenience to use and interference with their
said it is due to religious prohibition,100 (50%) normal body processes.
attributed it to fear of the side effect, 20 (10%) said
Question 3: What is the influence of marital status on the preference of IUCD as family planning method?
Table 4.7: Responses on the influence of Marital Status on the preference of IUCD usage.
Spouse Awareness Status Responses Number of respondents Percentage
Spouse aware Yes 80 73
Spouse not aware No 30 27
Total 110 100
From the table above, it is clear that out of the 110 whereas 30(27%) said their husband have no idea
women using IUCD, 80 (73%) said that their they were using IUCD.
husband has the knowledge about their usage,
Question 4: What is the influence of parity (number of children) on the preference of IUCD.
Table 4.8: Responses on the number of children prior to preference of IUCD

Responses Number of Respondents Percentage
0-3 50 25
4-6 140 70
7-9 10 5
10-15 - -
Total 200 100
A total of 50 (25%) of the respondents from the have 7-9 children before they started using family
table above affirmed that they have between 0-3 planning.
children, 140 (70%) have 4-6 children and 10 (5%)
Question 5: What is the most widely used family planning methods.

Table 4.9: Responses on the most widely used Family Planning Method
Family Planning Methods Number of Respondents Percentage
IUCD 110 55
Pill 20 10
Female condom 40 20
Injectable 10 5
Natural family planning 20 10
Total 200 100
From the above table, 110 (55%) of the women were condom for family planning, 10 (5%) were using
using IUCD, as a method of family planning, 20 injectable, 20 (10%) were using natural family
(10%) were using pill, 40 (20%) were using female planning method.
Question 6: Whose decision is the number of children wanted based on?
Table 4.10: Responses on whose decision the number of children is based

Decision on number of children Number of respondents Percentage
Male spouse same number of 70 35
children
Female spouse on more number of 90 45
children
In-laws decision on fewer number 30 15
of children
Husband do not know 10 5
Total 200 100
From the above table, 70 (35%) of respondents were based on in-laws and 10 (5%) do not know if
wanted same number of children as their husband, their husbands want the same number of children.
90 (45%) the wives wanted more children, 30 (15%)
Question 7: Who decides whether family planning should be used?
Table 4.11: Responses on who decides on the use of Family Planning

The woman 6 5
The husband 44 40
Joint decision 60 55
Total 110 100
The table above showed that out of the 110 the husband’s decision, whereas 60 (55%) were a
respondents that are using IUCD, 6(5%) decision to joint decision.
use IUCD was the woman’s, 44 (40%) said it was
Question 8: Does fear of side effects prevent women of child bearing age from using IUCD?
Table 4.12: Responses on whether fear of the side effects prevent usage of IUCD
Responses Number of Responses Percentage
Yes 90 45
No 110 55
Total 200 100

The table above revealed that 90 (45%) of the (55%) said that it is not the fear of the side effect
respondents indicated that the fear of the side effect that prevented them from using IUCD.
prevented them from the use of IUCD, while 110
Question 9: Were the women ever told what to do if they experience any of the side effect.
Table 4.13: Responses on the information about what to do if side effect arises
Yes 150 75
No 50 25
Total 200 100
From the above table, 150 (75%) of respondents experience side effect when using IUCD, while 50
indicated that they were told what to do if they (25%) were not told.
Question 10: Do women feel safe when they use IUCD?
Table 4.13: Views of Respondents on the safety of IUCD usage

Responses Numbers of Respondents Percentage
Strongly Agree 60 30
Agree 70 35
Disagree 10 5
Strongly Disagree 60 30
Total 200 100
Table 4.14 shows that 60 (30%) of respondents (35%) agreed, 10 (5%) disagreed, while 60 30%)
strongly agreed that IUCD makes them feel safe,70 strongly disagreed that it is not safe to use.
Question 11: Will creating awareness increase the preference of IUCD by women
Table 4.15: Responses on the IUCD preference with increased awareness

Yes 140 70
No - -
Do not know 60 30
Total 200 100
The above table revealed that 140 (70%) of the the preference of IUCD, whereas 60 (30%) do not
respondents affirmed that awareness will increase know.
Question 12: what is the rating of the overall preference of IUCD?
Table 4.16: Views of Respondents on the general preference of IUCD usage

Very good 30 15
Good 100 50
Uncertain 60 30
Bad - -
Very bad 10 5
Total 200 100
Table 4.14 shows that 60 (30%) of respondents said good, 60 (30%) are uncertain while 10 (5%) said
that IUCD use is very good, 100 (50%) said it is that IUCD usage is very bad.

Discussion course of this study as indicated by 90% of the

The indications for family planning are usually respondent, this is in agreement with Jimoh (2004)
spacing or limiting births, this could be influenced who stated that, accidental and ectopic pregnancies
by maternal age, parity, number of children and might occur with the use of IUCD.
socioeconomic status. On the question on whether
women of child bearing age prefer IUCD over other On the question on the possible influence of parity
family planning methods, it was observed from this on the use of IUCD. We observed that women who
study that 90% are doing family planning and 55% have had 4-6 children are more likely to use IUCD.
among them preferred the use of IUCD. This is not Previous report indicated that IUCD is a safe and
surprising as majority of respondents were less than effective method of family planning (Aisen, 2007).
40 years and it preference was highest among clients This is also demonstrated in the study, as majority of
with 3-6 children. This represents a real period when the women that were using the method have had
they need low number of children. These responses their desired number of children, hence were
affirmed the assertion of Adegbola and Ogedengbe satisfied with the method and 90% did not
(2008) that IUCD is widely preferred among women experience any complication during usage.
in Lagos State. Moreover, it is clear that husbands Furthermore 55% reported that they will use it
are in support of IUCD usage which will encourage again. Our finding is consistent with previous report
the women to go for IUCD. by Udigwe (2006) who affirmed that 64% of IUCD
user would chose it again. Thus, creating awareness
Intrauterine device is well preferred among women, will increase IUCD usage as indicated by 40% of the
though their uses are invariably low, with fear of respondents and a single act of motivation is
side effects, religious prohibition and opposition required for long time use.
from their husband influencing the low or reducing
IUCD usage. On the question on the main reasons Conclusion
that can prevent women of child bearing age from IUCD are widely preferred and tolerated, although
using IUCD, we observed that husband dominance rare complications are reported. Majority of the
based on requiring more number of children is a respondents still consider the benefit of
factor that militate against the use of IUCD. This contraception more than these complications.
finding was in consonance with the report by Ojiyi Though, in spite of its long duration of action,
et al. (2011), that various factors such as poverty, majority of respondents used it for spacing births.
poor access to contraceptive services, community The duration of its use is positively related to the
pressure, mate or husband dominance and religious number of living children. The mass media should
belief have been identified as being responsible for be encouraged to play a more active role in the
this low contraceptive usage. Igwegbe et al. (2010) promotion of the use of this effective reversible
in a related research noted that risk of ectopic long-term contraceptive method. Effective
pregnancy, fear of litigation and misinformation counseling should include duration of its action.
limit the use of IUCD. However, the perceived fear Those desirous of early return to fertilization will
might have derived from unfounded rumors relating also benefit from it as there is a prompt return to
to the methods and the people’s ignorance of the fertility once IUCD is removed. It is also very
workings and methods than from the actual effective as an emergency contraceptive when used
experiences. appropriately, it promotes maternal health.
On the effect of marital status on the preference of Recommendation/suggestions for further studies
IUCD as a family planning method, the study Bases on the issues raised, the following points are
revealed that women who use IUCD were married recommended:
and therefore they face little or no challenges, this
affirmed that they are well informed about method Awareness of IUCD should be intensified among
by health workers and the problems they might women of child bearing age to control the number of
encounter and what to do if they experience such births. Health workers should counsel women on the
problems. A previous report (Ojiyi, 2011), in knowledge and precepts regarding IUCD safety.
particular opined that IUCD are indicated in any Government and non-government should provide
woman who requested for it. The method has been more educational opportunities in the rural area for
adequately and appropriately researched and found the purpose of teaching birth control methods
to have no contra-indication to it use. On the other especially the use of IUCD. More primary health
hand, there is birth or pregnancy termination in the centres with strong family planning facilities should

be made available in the rural areas. Religious underestimated. British Medical

leaders should play very strong role in the decision Journal;3(12):398.
to use contraceptives among the people. It is Dawn, S. (2012). Contraception. Health disease
therefore necessary for religious leader to be and condition content. Medical Review
educated on the benefits of contraceptives use. Board: 5
An important step in improving family planning is Dowd, M.J.O. and Philip, E.E. (2002). Narrative
the involvement of men. Health workers should historical review in; the history of Obstetric
conduct campaign to educate men about family and Gyneacology. The Parthenon Publishing
planning and the role they can assume in family Group Ltd. Casterton Hall; 1:1-40.
planning. Sustained motivation, health education on Drtiz, M.E. and Croxatto, H.B. (2007). Copper T
the availability and benefits of IUCD and provision intrauterine device and levonorgestrel
of free commodity and services shall increase it intrauterine system: biology bases of their
utilization and improve maternal health in the mechanism of action. Contraception;
community. 75(34):16.
Emuveyan, E.E. and Dixon, R.A. (2005). Family
Further studies should include reproductive health Planning clinics in Lagos Nigeria. Clients,
care provider perception for greater insight into methods acceptance and continuation rates.
contraceptives decision making process. Since the Nigerian Medical Journal; 28:19-23.
majority of the rural people still rely on the Etuk, S.J., and Ekanem, A.D. (2005). Knowledge,
traditional birth control methods, it would be attitude and practice of family planning
necessary for researchers to study these methods amongst women with unplanned pregnancy in
with the view to improving on their success rate. Calabar, Nigeria. Nigerian Journal of
Physiological Sciences; 18:65-71.
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Original Research
SJMLS-2(1)-2017-011
Menstrual Training and Hygiene Management Among Adolescents in
South-Western Nigeria: A Cross-Sectional Study
Olusola John Fatunmbi 1, Saheed Opeyemi Usman* 2, Afusat Adesina 3, Oluwasogo Sunday
Odesanmi 4, Ibiwumi Nafisat Usman 5, Adebola Tolulope Odesanmi 6, Ndumiso Tshuma 7,
Jessica Yun 8, Olaiya Paul Abiodun 9.
Department of Laboratory Services, Union Diagnostics, Osogbo, Nigeria 1, Department of Chemical
Pathology, Faculty of Medicine, Nnamdi Azikiwe University, Nnewi, Nigeria 2, Howards University
(HOWARD) Continuous Education Centre, Lagos, Nigeria 3, Federal College of Education, Osiele,
Abeokuta, Nigeria 4, Department of Community Medicine, Ladoke Akintola University of
Technology, Osogbo, Nigeria 5, Federal College of Education Medical Centre, Abeokuta, Nigeria 6,
Community AIDS Response, Johannesburg, South Africa 7, Community AIDS Response,
Johannesburg, South Africa 8, Doctors with Africa, CUAMM, Juba, South Sudan 9.
Author for Correspondence *: Senatorhopsy@yahoo.com/+234-803-467-6223
Abstract of the respondents had their menarche (first

Menstruation is a normal physiological process that menstruation) around 12 to 16 years of age, with the
begins during adolescence and may be associated mean age ± SD being 13.02 ± 1.94 years. 216
with various symptoms occurring before or during (35.0%) experienced dysmenorrhoea (painful
the menstrual flow. Normal menstruation depends menstruation) during their last menstrual period and
on a highly-coordinated interaction between the menorrhagia by 28 (6.3%) of the respondent. Also,
hypothalamus, pituitary glands, ovaries and 128 (28.7%) of the respondents have had a cycle <
endometrium, with all events usually occurring in a 21 day or >35 days within their last three menstrual
cycle time frame often between 21 to 35 days. This cycles. Pre-menstrual training is common among
study was carried out to determine the influence of these adolescent girls as it is evident in their
pre-menarcheal training on menstrual hygiene menstrual hygiene practices. However,
practices, the various menstrual disorders among dysmenorrhoea and menorrhagia are common
the girls, as well as, the influence of educational problems among adolescent girls thus health
status on menstrual hygiene practices, with a view education and health promotion are the best ways to
to making necessary recommendations that would deal with menstrual hygiene & disorder issues
help improve such practices. This cross-sectional effectively.
study was carried out in South Western Nigeria. The
target population was adolescent girls in this region. (Keywords: Training, adolescent, Nigeria,
A multi-stage sampling technique was used to select menstrual, hygiene)
the respondents. All data were statistically analysed,
using statistical package for the social sciences
Introduction
(SPSS) and statistical test of significance was
Adolescence can be described as the transition
performed with Chi-Square test. A total of 446
consenting respondents participated in the study
period from childhood to adult. It is a period during
with a mean age ± SD of 14.72 ± 2.68 years. Most which pubertal development and sexual maturation
happen. In girls, it marks a special period signifying

the transition from girlhood to womanhood. This Sudan, some researchers reported that only 73% of
period of transition is marked with the onset of the girls interviewed experienced menarche as at the
menarche, which signifies a crucial landmark in time of the interview, with the mean age of 13.07
girls’ lifetime. During pubertal development, years, which was 0.9 years younger in the urban
hormonal, cognitive, psychological, physical, among girls. The majority of the girls (76.4%) experienced
other changes occur simultaneously in such delayed menarche while 68.5% had regular period
individual, with variations from person to person, with cycle length ranging between 21 to 35 days.
due to several factors including genetic, They also reported 83.1% dysmenorrhoea and
environmental, nutritional, among other factors. 59.8% pre-menstrual symptoms (Ali et al., 2011). In
Menstruation, a very crucial event in the India, it was revealed that abnormal cycle length
reproductive life of women. It is a normal was common and affected 30.48% of the girls, with
physiological process that begins during adolescence 56.15% dysmenorrhoea experience and 56.16% pre-
and may be associated with various symptoms menstrual syndrome reported. The mean ages for
occurring before or during the menstrual flow menarche were 13.51 and 13.67 years for urban and
(Adinma and Adinma, 2008). Regular menstruation rural areas respectively (Dambhare et al., 2012).
depends on a highly-coordinated interaction between Authors of the Lebanese research on pattern of
the hypothalamus, pituitary glands, ovaries and menstrual disorders reported 54.0% pre-menstrual
endometrium, with all events usually occurring in a syndrome, 43.8% irregular duration of menstruation
cycle time frame often between 21 to 35 days. and 38.1% dysmenorrhoea (Karout et al., 2012).
Menarche, which is the first menstruation period of
life is a milestone that signifies maturation of Moreover, in Ethiopia, the authors of a study on
reproductive potential and physiological growth and menstrual pattern in the Northwest reported that, a
this normally happens at the age of 11 to 15 years normal cycle of 21 to 35 days was observed in
most often and menopause, which is the end of 70.3% of the girls, mean duration of flow was 4
woman’s reproductive phase, most commonly days with a range of 2 to 7 days, irregular cycles
occurring between the age of 45 to 55 years observed in 42.8% of the girls, 39.7% got
(Edmonds, 2008). Menstrual disorders such as information about menarche from their mothers,
dysmenorrhoea, pre-menstrual symptoms, delayed 26.6% from friends and 21.8% through teachers
menarche, among others, generally cause some while the mean age was 16.9 years, the mean age at
apprehension among adolescents including their menarche was 15.8 years (Zegeye et al., 2010). In
family members thus further justifying the reason to Northern Nigeria, a 25.6% pre-menstrual symptoms
know the pattern of menstrual cycle, the training, and 69.0% regular menstruation were reported
practices and variations (American College of among secondary school girls with mean age of
Obstetricians and Gynecologists, 2006; Adams 15.35 years while the mean menarche age was 12.53
Hillard, 2002). years (Sulayman et al., 2013). This study is therefore
carried out to determine the various menstrual
The authors of the 2016 cross-sectional study on disorders among the adolescent girls, the influence
menstrual disorders revealed that dysmenorrhoea of pre-menarcheal training on menstrual hygiene
was the most common menstrual disorder with practices, as well as, the influence of educational
48.82%, followed by abnormal cycle length status on menstrual hygiene practices, with a view to
(19.96%) and menorrhagia (11.80%) among girls making necessary recommendations that would help
whose average was 13.12 years (Anup et al., 2016). improve such practices.
Another research on the impact of pre-menarcheal
training on menstrual practices and hygiene showed Research Hypothesis
that the mean age was 14.9 years and 55.2% of the  Educational status has no significant influence
girls received pre-menarcheal training, with mothers on menstrual hygiene practices
(74.7%) being the most common source of  Relationship with mothers have no significant
information (Aniebue et al., 2009). In Eastern effect on pre-menarcheal training

 Educational attainment of mother has no Statistical Analysis

significant effect on pre-menarcheal training Data was statistically analysed using Statistical
Package for the Social Sciences (SPSS) for windows
Materials and Methods version 20.0 software (SPSS Inc., Chicago, IL,
This cross-sectional study was carried out in the USA). All data were expressed as Mean ± Standard
South-Western Nigeria. The target population was Deviation (SD). Frequency counts were generated
adolescent girls in cities in this region. A semi- for all variables and statistical test of significance
structured questionnaire was administered was performed with Chi-Square test. Significance
consecutively on 446 respondents. Demographic and was fixed P ≤0.05 and highly significance is p ≤
socio-economic information obtained were included. 0.01.
A multi-stage sampling technique was used to select
the respondents from metropolis. In stage 1 from a Results
sampling frame of the entire number of local Socio-Demographic Data
government areas in the States in that region, one- A total of 446 consenting respondents participated in
third number of LGAs was selected using simple the study. The mean age ± SD is 14.72 ± 2.68 years.
random sampling method. In stage 2, a list of towns Most of the respondents Christians, 313 (70.2%) and
in each of the selected LGA’s was randomly made. are mainly in senior secondary school, 211 (47.3%).
In stage 3, houses in the towns were randomly The girls are mainly from a nuclear family
selected. The final stage involved in the selection of background, 330 (74.0%). The mothers’ level of
consenting adolescent girls. The questionnaires were education was mainly first degree, 122 (27.4%).
then administered on the respondents. Three hundred and sixteen, which is equivalent to
70.9%, of the respondents had pre-menstrual
Sample Size training, that is, information about menstrual cycle
Sample size calculation was done using 95% before first cycle, as they were told about and made
confidence interval, 0.05 precision and prevalence to expect the first bleeding, with this done by
rate. Using prevalence of menstrual abnormalities of mother, as reported by 236 respondents (52.9%).
45.6% in school girls by (Adinma and Adinma, Three hundred and twenty-one (72.0%) of them
2008). With the use of Leslie Fischer’s formula for were told how to collect menstrual blood, mainly
population >10,000, the formula for sample size informed that they should collect the blood into
calculation is: n = Z2PQ/d2 (Daniel, 2013). sanitary pads and majority were told how to dispose
n = Z2PQ/d2 of the materials used to collect the menstrual period,
Where: with toilet/pit latrine, dust bin and burning listed as
N = minimum sample size, d = degree of precision ways of disposal. Meanwhile, 387 (86.8%) of the
(taken as 0.05), respondents currently use sanitary pad as the
Z = standard normal deviation at 95% confidence menstrual absorbent/material to collect their
interval which is 1.96, menstrual period. Menorrhagia, which is an
P = proportion of the target population (estimated at abnormally heavy or prolonged bleeding, that is, the
22.2% which is 45.6/100 = 0.456), use of four or more fully soaked pads a day or
Q = alternate proportion (1-P) which is 1-0.456= bleeding more than 8 days, was said to have been
0.544 experienced by 28 (6.3%) of the respondent during
N = (1.96)2 (0.456) (0.544) = 382 the last menstrual period. Also, 128 (28.7%) of the
(0.05)2 respondents have had a cycle < 21 day or >35 days
within their last three menstrual cycles.
Also, adding a 5% non-response rate, the minimum
sample size (n) will be 5/100 X 382 = 19 In table 2, most of the respondents are reported to
have had their menarche (first menstruation) around
Thus, it will be 19 + 382 = 401 = N 12 to 16 years of age, with the mean age ± SD being
13.02 ± 1.94 years. Most of them reported the first

menstruation experience to be frightening, 146 experienced dysmenorrhoea (painful menstruation)

(32.7%). With last menstrual blood flow duration during their last menstrual period, with 125 (28.0)
being reported mostly as 4 and 5 days, the mean ± reportedly using drugs during the course of the pain
SD of blood flow duration is 4.08 ± 1.02 days. chiefly pain killers or analgesics such as
Regarding the amount of the last menstrual blood acetaminophen and non-steroidal anti-inflammatory
flow, most of the respondents reportedly used 2 pads drugs (NSAIDs) and prescribed by their mothers in
per day. Two hundred and sixteen (35.0%) most of the cases.
Table I: Socio-demographic data of respondents

Age Group (years)
10 years 37 (8.3)
11 years 26 (5.8)
12 years 31 (7.0)
13 years 61 (13.7)
14 years 61 (13.7)
15 years 49 (11.0)
16 years 53 (11.9)
17 years 35 (7.8)
18 years 55 (12.3)
19 years 38 (8.5)
Type of family
Nuclear Family 330 (74.0)
Extended Family 89 (20.0)
No Response 27 (6.0)
Religion
Christianity 313 (70.2)
Islam 133 (29.8)
Level of education
Junior Secondary School 203 (45.5)
Senior Secondary School 211 (47.3)
Ordinary Level (O’Level) Degree 25 (5.6)
Undergraduate 7 (1.6)
Position in family
First Daughter 218 (48.9)
Middle Daughter 131 (29.4)
Last Daughter 55 (12.3)
Only Daughter 34 (7.6)
No Response 8 (1.8)
Relationship with mother
Very Close 314 (70.4)
Close 92 (20.6)
Ordinary 20 (4.5)
Not Close 5 (1.1)

Table 2: Pre-menstrual training and menstrual hygiene practices

Current menstrual period absorbent/material disposal

Water Closet 73 (16.4)
Dustbin 61 (13.7)
Burning 56 (12.6)
Pit Latrine 85 (19.1)
Washing (Cloth) 51 (11.4)
Farmland/Farm Location 50 (11.2)
Anywhere 5 (1.1)
Age at menarche (first menstruation) in years
9 years 4 (0.9)
10 years 25 (5.6)
11 years 75 (16.8)
12 years 90 (20.2)
13 years 88 (19.7)
14 years 78 (17.5)
15 years 36 (8.1)
16 years 22 (4.9)
17 years 15 (3.4)
18 years 12 (2.7)
19 years 28 (5.3)
Experience at first menstruation
Confusing 116 (26.0)
Frightening 146 (32.7)
Expectant 124 (27.8)
Attitude towards subsequent menses
Undesirable 68 (15.2)
Unprepared 153 (34.3)
Satisfactory 154 (34.5)
Duration of last menstrual blood flow (in days)
2 days 12 (2.7)
3 days 112 (25.1)
4 days 153 (34.3)
5 days 127 (28.5)
6 days 13 (2.9)
7 days 8 (1.8)
Amount of last menstrual blood flow
1 pad/day 36 (8.1)
2 pads/day 203 (45.5)
3 pads/day 117 (26.2)
4 pads/day 17 (3.8)

5 pads/day 12 (2.5)
Dysmenorrhoea (painful menstruation) experience
Mild 67 (15.0)
Moderate 123 (27.6)
Severe 26 (5.8)
Pre-menstrual symptoms
Depression 24 (5.4)
Pimples 84 (18.8)
Generalized Fatigue 27 (6.1)
Breast Tenderness/Pain 94 (21.1)
Mood Changes 86 (19.3)
Menstrual symptoms
Fatigue 39 (8.7)
Irritation 36 (8.1)
Nausea 18 (4.0)
Headache 39 (8.7)
Backache 69 (15.5)
Dizziness 29 (6.5)
Diarrhoea 30 (6.7)
Mood Swing/Change 48 (10.8)
Table 3: Chi square result showing factors influencing pre-menstrual training and menstrual hygiene
Variables χ² df Critical value Decision
Educational status on menstrual 17.136 12 21.03 Accepted

hygiene practices
Relationship with mothers on 5.354 8 15.51 Accepted

pre-menarcheal training
Educational attainment of mother 14.634 14 23.69 Accepted

on pre-menarcheal training
1) Educational status has no significant influence Discussion

on menstrual hygiene practices This research outcome has shown that most of the
2) Relationship with mothers have no significant respondents were in 12 to 16 years’ age group, with
effect on pre-menarcheal training the mean age ± SD being 14.72 ± 2.68 years. This is
3) Educational attainment of mother has no very similar to other research outcomes which
significant effect on pre-menarcheal training showed their mean age to be in this range (Anup et
al., 2016; Sulayman et al., 2013; Dambhare et al.,
The null hypothesis is rejected when the test statistic 2012; Ali et al., 2011; Zegeye et al., 2010; Aniebue
is greater than the tabled value or critical value. et al., 2009). Three hundred and sixteen, which is
equivalent to 70.9%, of the respondents had pre-

menstrual training from their mothers, that is, cycles. The outcome differs from the Eastern Sudan
information about menstrual cycle before first cycle, and Ethiopian studies which indicated that 68.5%
as they were told about and made to expect the first and 70.3% of respondents respectively had regular
bleeding. This is slightly similar to the outcome of period with cycle length ranging between 21 to 35
another research which reported that 55.2% of the days (Ali et al., 2011; Zegeye et al., 2010). This can
respondents received pre-menarcheal training and be considered a regular event especially as ovulation
perhaps mainly through their mothers (Aniebue et is said to occur in the first two years after menarche
al., 2009). In this study, pre-menarcheal training was (Adams Hillard, 2012). Pre-menstrual symptoms are
found to be significantly associated with the found to be very common among these adolescents
educational attainment of the respondents’ mothers, with mood changes and breast tenderness. These
thus influencing the probable information passed on findings are in agreement with other studies; 59.8%
to the girls. Among the respondents, 387 (86.8%) pre-menstrual symptoms in Sudan (Ali et al., 2011),
currently use sanitary pad as the menstrual 56.16% pre-menstrual syndrome in India (Dambhare
absorbent/material to collect their menstrual period. et al., 2012) and 25.6% pre-menstrual symptoms in
This is not strange owing to the fact that the pads are Northern Nigeria (Sulayman et al., 2013).
readily available and affordable, perhaps most girls
believe the pads help prevent genital infections. Most of the respondents had their menarche (first
Most of the information on pre-menstrual training menstruation) around 12 to 16 years of age, with the
were obtained from the mother rather than from mean age ± SD being 14.72 ± 2.68 years. This is in
health workers or hospital or even school through contrast to the Sudanese research outcome which
their teachers. This finding highlights the need for reported 76.4% delayed menarche (Ali et al., 2011),
organized health information and education for as well as the mean age at menarche reported as 15.8
adolescents to complement family life education years in Ethiopia (Zegeye et al., 2010), but similar
learned from home. This can potentially help correct to the outcome of the study in Northern Nigeria
the wrongly information and enhance evidenced- where the mean menarche age of 12.53 years was
based correct peer health education propagation. reported (Sulayman et al., 2013) and in India, where
the mean ages for menarche were 13.51 and 13.67
Two hundred and sixteen (48.4%) experienced years for urban and rural areas respectively
dysmenorrhoea (painful menstruation) during their (Dambhare et al., 2012). This shows that generally
last menstrual period. This is slightly in agreement girls experience menarche at different ages, the
with other studies, as 48.82% dysmenorrhoea was timing of which is influenced by the female biology
reported in 2016 (Anup et al., 2016), 56.15% coupled with environmental factors especially
dysmenorrhoea in India (Dambhare et al., 2012) and nutrition as well as genetics.
38.1% dysmenorrhoea reported in Lebanon (Karout
et al., 2012) while in contrast from the outcome of The acceptance of the first hypothesis on
the Eastern Sudan study that showed 83.1% educational status on menstrual hygiene practices
dysmenorrhoea. The painful menstruation was shows that education doesn’t necessarily determine
reportedly said to have hampered certain part of the the menstrual hygiene practices. Also, the
respondent’s social life or even schooling activities. acceptance of the second hypothesis on the relation
Menstrual symptoms included headache, fatigue, with mothers on pre-menarcheal training shows that
backache and mood swings. These symptoms the training is not dependent on the closeness of the
complicate the issue of menstruation. These adolescent girl with the mother. Meanwhile, the
menstrual symptoms form part of regular women acceptance of the third hypothesis on educational
cycle largely because dysmenorrhoea begins around attainment of mother having no significant effect on
the time menstruation begins, with the pain often pre-menarcheal training shows that the education of
around the pelvis or lower abdomen. Furthermore, the mothers does not necessarily determine the
128 (28.7%) of the respondents have had a cycle < possible information that would be stepped down to
21 day or >35 days within their last three menstrual the young girls.

Conclusion and Recommendation school girls. The Pan African Medical

Pre-menstrual training is common among these Journal;2(9): doi: 10.4314/pamj.v2i1.51708.
adolescent girls as it is evident in their menstrual Anup, K., Roshan, R., Rutuja, P. and Jayashree, J.
hygiene practices. However, dysmenorrhoea and (2016) .A Cross-Sectional Study on
menorrhagia are common problems among Menarcheal Age and Menstrual Disorders.
adolescent girls. Health education and health International Journal of Health Sciences and
promotion that include sexual and reproductive Research; 6 (6): 19-23.
health are the best ways to deal with menstrual Dambhare, D. G., Wagh, S. V and Dudhe, J. Y.
hygiene and disorder effectively. It is therefore (2012). Age at menarche and menstrual cycle
advised that menstrual hygiene be included in the pattern among school adolescent girls in
high school curriculum and implemented by Central India. Global Journal of Health
teachers in order to enhance the teachings at home Science; 4(1):105–111.
by the mothers of these young girls. Daniel, W. W. (2013). Biostatistics : A Foundation
for analysis in the health science. Journal of
Conflict of Interest Declaration Chemical Information and
No conflict of interest. Modeling;Biothechnology Research
International: 1689–1699.
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Adams Hillard, P. J. (2002). Menstruation in young Obstetrics & Gynaecology, Dewhurst’s
girls: A clinical perspective. Obstetrics and Textbook of Obstetrics & Gynaecology. doi:
Gynecology; 99(4):655-662. 10.1002/9780470753354.
Adinma, E. D. and Adinma, J. I. B. (2008) Karout, N., Hawai, S. M. and Altuwaijri, S. (2012).
‘Perceptions and practices on menstruation Prevalence and pattern of menstrual disorders
amongst Nigerian secondary school girls.’, among Lebanese nursing students. East
African Journal of Reproductive Health; 12(1): Mediterranean Health Journal;18(4):346-352.
74–83. Sulayman, H., Yusuf, A., Adesiyun, A., Ameh, N.,
Ali, A. A., Rayis, D. A., Mamoun, M. and Adam, I. Avidime, S., Enobun, N., Muazu, A., Ojabo, A.
(2011). Age at menarche and menstrual cycle and Ozed-Williams, I. (2013). Age at menarche
pattern among schoolgirls in Kassala in Eastern and prevalence of menstrual abnormalities
Sudan; 3:111–114. among adolescents in Zaria, northern Nigeria.
American College of Obstetricians and Annals of Nigerian Medicine; 7(2): 66.
Gynecologists (2006). ACOG Committee Zegeye, D. T., Megabiaw, B. and Mulu, A. (2009).
Opinion No. 349, November 2006: Age at menarche and the menstrual pattern of
Menstruation in girls and adolescents: using the secondary school adolescents in northwest
Ethiopia. BMC Women’s Health;9: 29.
menstrual cycle as a vital sign. Obstetrics and
Gynecology; 108(5): 1323–1328.
Aniebue, U. U., Aniebue, P. N. and Nwankwo, T. O.
(2009). The impact of pre-menarcheal training
on menstrual practices and hygiene of Nigerian


Original Research
SJMLS-2(1)-2017-012
Knowledge of Attitude and Influences of Alcoholism in Sokoto, Nigeria
Ikpeama Chizoba Anthonia 1, Ikpeama Chinwe Joy 2, Ikpeama Osita John 3, Ogwuegbu Julie Uchechi 4
Federal Medical Centre Birinin Kebbi 1, School of Nursing Tawa Bello School of Post-Basic Midwifery
Usmanu Danfodio Sokoto 2, Department of Public Health Imo State University Owerri 3, Department of
Medicine Imo State University Owerri 4
Author for Correspondence: ikpeama35@gmail.com/+234-806-261-9025
Abstract (Charles, 2006). It is also defined by the Oxford

This study was carried out to determine the English mini dictionary as a person addicted to
knowledge and influences of alcoholism in Sokoto. A
drinking. Alcoholism is also known as alcohol
descriptive research design was used for this study
dependence by some authors (Waltone, 2006). The
and the population size of 150 was used through
questionnaire and interview sampling technique.
risk of alcoholism for an individual and its incidence
Findings shows that alcoholism among youth is on in the society depend on the amount of drunk.
the increase and it affects men more within the age Countries such as France and U.S where heavy
of 36-75years. Also, the finding shows that drinking is socially acceptable have the highest rate
socioeconomic status and ignorance of the young of drinking.
has a great influence in the increase rate of
alcoholism so due to the importance of youths (the Alcoholism impair intellectual function, physical
productive age of the nation) in our society and skills, memory and social skill such as conversation.
family and seeing the deteriorating effect of this
Heavy consumption of alcohol also causes
habit condition on them, physically, mentally,
cardiomyopathy, peripheral neuritis, cirrhosis of the
psychologically and morally. The government should
create more awareness on the condition, its causes
liver and enteritis (Waltone, 2006).
and ways of preventing it through the media. There
is the need to promulgate a law that regulates the The treatment of alcoholism is usually given in a
consumption rate of alcohol particularly among the psychiatric hospital where alcoholic is first denied
youth in the area. Also, the health practitioners and then helped to understand the psychological
(clinicians, psychiatrist, and nurses) should manage pressure that lead to his heavy drink.
those affected by offering the best possible physical,
social and psychological care to prevent them from Alcohol has been used religiously in the celebration
developing alcohol-related complications.
of ceremonies or parties and as a medicine for
thousands of years (Wilson, 2004). Throughout
Introduction history, alcohol has been more popular than any
Alcoholism is a habitual intoxication, prolonged and
other drug in the world especially in developed
excessive intake of alcoholic drinks leading to the
nations despite numerous prohibitions against it. It is
breakdown in health and addiction to alcohol such
often portrayed in advertisement on electronic media
that abrupt deprivation leads to severe withdrawal
like television and in movies as part of good time at
symptoms such as tremor, anxiety, hallucinations
the beach, social occasions. Alcohol moderation
and delusion. Alcoholism could also be defined as
can enhance social occasions by loosening in and
the loss of control over drinking behavior and or the
creating a pleasant feeling of relaxation, but the use
lack of ability to reframe from becoming intoxicated

of alcohol can also be unhealthy. This is the 3. Socio-economic status may play no role in
contradictory role in human life like other drugs, it contributing to alcoholism
has physiological effect in the body that can impair 4. Alcoholism is associated with health
functions in short term and cause devastating complications.
damage in long term for some people. Alcohol
becomes addiction leading to a life time of Objectives of the study
discovery or for a few to debilitation and death 1. To determine the gender that is more vulnerable
(Pletcher,2005). of alcohol consumption
2. To determine the type of alcohol mostly
About 49% of American adult abstain from consumed by youth in the study area.
alcoholism or drink fewer than 12 drinks per year. 3. To determine the group age and educational
About 22% are light or occasional drinkers and 20% level of youth that indulge in alcoholism
are risky drinkers, meaning the occasionally or 4. To create awareness on the problems (medical
regularly drinks excessively. Alcohol is responsible and social) associated with alcoholism to the
for about 85,000 deaths per year among Americans readers, the local community and society at
and it is the leading cause of death among adult of large.
age 15-24 years (Jacobson, 2004). Worldwide
alcohol causes 1.8 million deaths per year. Significance of the study
The significance of the study is to enable
The causes/reason of indulging in alcoholism are, researchers, health worker and public health workers
peer pressure, ignorance, alienation, changing social in identifying the causes/reasons why youths indulge
structure, unemployment, gender, brain dram, easy in alcohol as well as buttress the complications
access to alcohol and mindfulness (Hudu,2005). associated with alcoholism and ways of reducing it.
There are stages of alcoholism and they are as
follows: Research questions
1. Early stage alcoholism a. What are the causes/reasons why youth indulge
2. Middle stage alcoholism in alcoholism?
3. End stage alcoholism (Charles, 2006) b. What age group does youth start drinking and
which age group is at a higher risk?
There is effective therapy used in psychiatric c. Does ignorance and socio-economic status play
hospital to help drinker and their family and these a role in alcoholism?
include: d. What are the complications of alcoholism?
1. Motivational enhancement programme e. What measures can be taken to reduce the
2. Cognitive-behavioral coping skills therapy intake of alcohol among youth
(Walton, 2006)
Hypotheses
Also, alcoholism is extremely devastating to the a. There is no significance relationship between
family member and the society at large, and this alcoholism and ignorance.
situation made many researchers to investigate on b. Socio-economic status will increase alcoholism
the causes/reasons and complications of alcoholism among youths.
(Roth, 2006).
Research design
Statement of problems A cross-sectional form of descriptive survey
1. Most of the youth in the mammy market research design was used for this study. This is
military barrack in Sokoto, Nigeria have their because descriptive studies are used when the
reason for indulging in alcoholism characteristics of a population are either unknown or
2. Alcoholism is common among youth compared partially known (Hennekens and Buring, 2007) and
to more elderly persons in mammy market are because it examines the relationship between disease

(or other health- related state and other variables population is in few thousands, 10% will be
(risk factors) as well as access the burden of appropriate as the sample size.
alcoholism in this population. Information obtained
will aid in describing the study population as well as Instrument for data collection
help policy makers enact laws and tailor care and The main instrument for data collection consisted of
support programmes to meet the need of alcoholics structured interview guide. The structured interview
in the area. guide was used because most of adult males and
females in the area are not very literate. The
Area of study structured interview was in two sections A and B.
The study area is located in Dange-Shuni Local Section A, was made up of questions on socio-
Government Area of Sokoto State where 1 Brigade demographic data (gender, age, tribe, religion,
Army Barrack is located. The Military barrack marital status, occupation and level of education).
occupies about half a square kilometer. Mammy Section B, contained eight (8) questions on
market was introduced into the Nigeria army during knowledge and behavioral risk factors to alcoholism.
the British colonial era. Those days’ soldiers were
not allowed to go to the town for recreation, rather a Validity of the instrument
mini-market as it was called before was made The draft of the structured interview guide was
purposely for soldiers to feel at home. Later, it was approved by the project supervisor and validated by
changed to mammy market. Mammy market is now three lecturers in the School of Nursing Usmanu
a popular area in Sokoto which is now patronized by Danfodio University Teaching Hospital Sokoto. The
both civilian and soldiers. The Mammy market is validators were requested to examine the content of
widely known as a place where people come to the instrument in line with the objectives of the
drink local alcoholic beverages such as Burukutu, study to ascertain clarity and ability to elicit
Ogogoro and Omole. Other national and appropriate responses for the study. Modification
international drinks like Beer, Whisky, Star lager were made following validators comments.
brand, Guinness Stout and others. Food delicacies
such as pounded yam, pepper soup, semo are sold Reliability of the instrument
there. There are about 850 shops, where the above Split-half method was used in establishing the
foods and drinks are sold. Due to its popularity reliability of the instrument. Twenty (20) copies of
people from various area of life come to relax and the instrument were distributed once to twenty
for leisure in the market. These factors facilitate an respondents in Police Officers Mess Sokoto. The
increase in population and resultant increase in Police Mess was not part of the study population but
social activity which include increase in alcoholism another distant leisure mini market sharing the same
and prostitution. characteristics in a neighboring Local Government
area to Sokoto metropolis. Results of the single
Population of the study administration was divided into two equal halves
The accessible population of the study consisted of using odd and even numbers. Cronbach Alpha
an estimated four thousand five hundred (2,000) Correlation co-efficient was used in ascertaining the
adults (male/female) (18-35 years) in thirty different correlation co-efficient. Using Cronbach Alpha
areas in mammy market. Correlation, 0.89 was obtained. This showed a high
positive correlation and thus regarded as reliable (as
Sample/sampling technique. shown in appendix C).
The sample for the study consisted of 200 (one
hundred and fifty) adults’ males and females were Method of data collection
randomly drawn areas in mammy market area. Ten A letter of research approval (Appendix D) to enable
percentage (10%) of the accessible population was the researchers to administer the questionnaire to the
used as sample size. Nwana (2011) opined that if the respondent signed by the Principal of the School of
Nursing Usmanu Danfodio University Teaching

Hospital Sokoto. Five (5) trained research assistants Method of data analysis.
were involved in explaining to the respondents on Data collected were analyzed using descriptive
face to face basis the details of what the research is statistic of frequency count, normative percentage
meant for. and grand mean. Out of the two hundred
questionnaires distributed, one hundred and fifty
(150) copies of the structured interview distributed
representing (75.0%) were returned and used for
data analysis.
Table 1: This shows the Gender distribution of Youths that indulge in alcoholism
Gender Frequency Percentage
Male 85 56.7
Female 65 43.3
Total 150 100.0
Table 1 shows frequency distribution of alcoholism more than women. This may be because
respondent’s gender. It revealed that 85 (56.7%) of the belief that it sharpens their brain, because of
were males; while 65(43.3%) were females. The their body built/structure and also the type of job
male respondents were found to indulge in they do.
Table 2: Educational status of Adults that indulge in alcoholism.

Educational Status Frequency Percentage
Primary 53 35.4
Secondary 66 44
Tertiary 26 17.3
None 5 3.3
Total 150 100
Table 2 shows that alcoholism is more among adults 26(17.3%) and non-formal education 5(3.3%). This
that are educated to the primary 53(35.4%), and may be related to inadequate/lack of knowledge
secondary level 66(44%) compared to tertiary about the harmful effect of alcoholism.
Table 3: Ethnic distribution of Youths that indulge in alcoholism

Tribe Frequency Percentage
Hausa 31 20.7
Igbo 37 24.6
Yoruba 27 18
Others 55 36.7
Total 150 100
The table shows that the other tribes has a high 55(36.7%) followed by Igbo 37(24.6%) then Hausa
percentage of youths that indulge in alcoholism 31(20.7%) and Yoruba 31(20.7%).

Table 4: Distribution of Youths that indulge in alcoholism based on their Religious affiliation
Religion Frequency Percentage (%)
Islam 32 21.3
Christianity 33 22
Others 85 56.7
Total 150 100
The above table shows that other religion 85(56.7%) had a high percentage, followed by Christianity 33(22%)
and Islam with 32(21.3%).
Table 5: Distribution of Youths that indulge in alcoholism based on their Marital Status
Marital Status of Youth that indulge in alcoholism Number of Youth Percentage
Single 45 30
Married 55 36.7
Divorced 21 14
Widow 10 6.7
Widower 19 12.6
Total 150 100
The above table illustrates that alcoholism is This may be related to the belief that alcohol reduces
practiced more among married respondents tension, that is makes them to be relieved of most of
55(36.7%) followed by singles 45(30%), divorced their family problem.
21(14%), widow 10(6.7%) and widower 19(12.6%).
Table 6. Age distribution of Youths that indulge in alcoholism

Age(Years) Number of Youth Percentage
18 – 21 15 10
22 – 25 30 20
26 – 35 45 30
36 – 75 60 40
Total 150 100
The above table shows that 36 – 75 years is 60(40%) 45(30%), then 22 – 25 with 30 ( 20%) and 18 – 21
which is the highest, followed by age group 26 – 35 years with 15(10%) respectively.
Table 7. Occupational Distribution of indulgence in alcoholism among the Youths in Mammy

Occupation Number of Youth Percentage Degree (%)
Student 29 19.3 69.6
Trader 45 30 108
Farmer 19 12.7 45.6
Civil servant 33 22 79.2
House wife 15 10 36
Beggar 9 6 21.6
Total 150 100 360
The occupational status of the respondents varied; 19(12.7%), civil servants 33(22%), house wives
student 29(19.3%), traders 45(30%), farmer 15(10%) and beggars 9(6%).

Table 8: Distribution of Youths that indulge in alcoholism based on the number of Children
Number of Children of Youth that Indulge In Alcoholism Frequency Percentage (%)
None 45 30
1–5 23 15.3
6 – 10 34 22.7
More than 48 32
Total 150 100
The above table shows that the Youths that indulge 45(30%). Those that had 1-5 youth 23(15.3%) and
more in alcoholism are those that have more than 10 6-10 youth 34(22.7%).
children 48(32%) followed by youth that have none
Table 9: Distribution of Youth that indulge in alcoholism based on the number of children in formal
educational.
Responses of Youth with Children in School Frequency Percentage (%)
Yes 64 42.7
No 31 20.7
Only Male 9 6
Only Female 5 3.3
All 41 27.3
Total 150 100
This table shows that youth whose response is yes had male children only, 5(3.3%) had only female
that their children are in school, 64 (42.7%) and children while 41(27.3%) had both male and female
31(20.7%) said they do not have children in school. children.
Among the youths with children in school, 9(6%)
Table 10: Distribution of Youths that indulge in alcoholism who are still able to perform their social
function.
Response of Youth Still Able to Perform Their Social Frequency Percentage
Function
Yes 112 74.7
No 38 25.3
Total 150 100
Table 10 above shows that out of 150 respondents, their social functions while 38 (25.3%) said they
112 (74.7%) said they were still able to perform could not perform their social functions.
Table 11: Distribution of reasons why Youths go in to drinking

Reasons Why Youth Drink Frequency Percentage
Peers 44 29.3
Pleasure 55 36.7
Frustration 23 15.3
None 28 18.7
Total 150 100

The above table shows that youth go in to by peers, 23(15.3%) did alcoholism due to
alcoholism for different reason; 55 (36.7%) were frustration in life and 28(18.7%) had No influence at
influenced by pleasure, 44(29.3%) were influenced all.
Table 12: Distribution of knowledge about the effect of alcoholism among the Youths
Response of Youth That Might Know the Effect of Alcoholism Frequency Percentage
Yes 49 32.7
No 101 67.3
Total 150 100
Table 12 above shows that majority of the youths responded that they knew the effect of alcoholism
101(67.3%) had no knowledge of the possible effect but still indulge in it.
of alcoholism on their health while 49(32.7%) youth
Table 13: Distribution of sources where Youths got information about the effect of alcoholism.
Source of Information Frequency Percentage
Friends 10 6.7
Mass Media 25 16.6
Health Personnel 18 12
None 97 64.7
Total 150 100
The above table shows that the frequency of youth information from Health Personnel 18 (12%),
that obtained information from Mass Media is friends 10 (6.7%) and None 97(64.7%).
25(16.6%) compared to those that obtained
Table 14: Distribution on the intention among Youths to stop alcoholism.

Responses of Youth Who Have Intention of Stopping Alcoholism Frequency Percentage
Yes 52 34.7
No 98 65.3
Total 150 100
This table shows that out of 150 respondents with High alcohol consumption is associated with an
varying intension of stopping alcohol, 98(65.3%) of increased risk of hypertension and that regular
the youth had no intention of stopping alcoholism alcohol intake predisposes to the development of
while 52 (34.7%) noted that they have intention of cerebrovascular episodes (Onuzulike, 2016). These
stopping the practice of alcoholism. factors are more pronounced during adulthood, and
knowledge of the risk factors of alcoholism is an
Discussion important step in the modification of lifestyle
Alcoholism is one of the leading public health behaviors conducive for optimal healthy life style.
menaces globally and is on the rise among the young Drinking too much alcohol can raise your blood
and elderly. A review conducted by Campbell pressure. To help prevent high blood pressure health
(1999) in Canada confirmed that heavy alcohol and other implications of alcoholism, it is vital to
consumption increases blood pressure regardless of limit how much alcohol one drinks and to ensure
gender or age. Drinking pattern was also observed in that one drinks not more than two drinks a day.
a previous report (Russell et al., 1991) and indicated
that heavy drinking of alcohol increase the risk of The Dietary Guidelines for Americans recommends
developing HBP and other cardiovascular diseases. that for overall health, women should limit their

alcohol to no more than one drink a day (Henderson years (10%). Previous report (Last, 2001) indicates
et al., 2002). The research revealed of the that risk factors such environmental, behavioral or
respondents 85 (56.7%) were males; while biological factor confirmed by temporal sequence,
65(43.3%) were females. More men indulge in usually in longitudinal studies, which if present
alcoholism more than women, this may be because directly increase the probability of alcoholism
of the believe that it sharpens the brain, because of occurring and if absent or removed reduces the
their body built/structure and also the type of job probability. Donna (2006) posited that a risk factor
they do. is something that increases an individual’s chances
of becoming an alcoholic.
Result showed that alcoholism is more among youth
that obtained primary 53(35.4%), and secondary In this study, we observed that the history of
level 66(44%) education compared to those with alcoholism in Sokoto, varied based on occupational
tertiary 26(17.3%) and non-formal education groups. The highest prevalence of alcoholism was
5(3.3%). This may be related to inadequate/lack of observed among traders (30%) followed by civil
knowledge about the harmful effect of alcoholism. servants (22%), students (19.3%), farmers (12.7%),
These perceptions and influences lead the individual housewives (10%) and beggars (6%). This finding is
to commit or not commit to a plan of action to an indication that alcoholism or moderate alcohol
promote healthy lifestyle. However, factoring in intake cut across every stratum of life who indulge
immediate competing demands, the individual then in the pleasure and excitement that is characterized
adopts the health promoting behavior (Pender, with alcoholism. Trader are the most common
1975). Pender (1975) and Pender and Colleagues people who indulge in alcohol in Sooto. The reason
(2002) states that an individual’s behaviors are for this observation may be due to the fact that have
driven by prior related health promotion behaviors, access to daily income.
as well as personal factors, including biological,
psychological, and sociocultural. We observed that youths with more than 10 children
are more likely to indulge in alcoholism (32%)
We observed a variation in history of alcoholism compared than those who have no children (30%),
based on ethnicity and religious affiliations. It was those with 1-5 (15.3%) and those with 6-10 children
noticed that other tribes had a high percentage (22.7%). Parental behavior has a great impact on
(36.7%) followed by Igbos (24.6%, Hausa their sibling or offspring. Siblings are more likely to
31(20.7%) and Yoruba (20.7%). On religious lines, indulge in alcoholism if their parents are alcoholics.
history of alcoholism varied from (56.7%) among Although, these perceptions and influences can
those with other religious affiliations, to (22%) potentially lead the individual to commit or not to
among Christians and 32(21.3%) among Muslims. commit to a plan of action to promote health.
However, factoring in the immediate competing
Result revealed that alcoholism is practiced more demands, the individual can potentially adopt the
among married respondents (36.7%) followed by health promoting behavior (Pender, 1975). Previous
singles (30%), divorced (14%), widow (6.7%) and report (Pender et al., 2002) indicated that an
widower (12.6%). This variation may be related to individual’s behaviors are driven by prior related
the believe that alcohol reduces tension, that is health promotion behaviors, as well as personal
makes them to be relieved of most of their family factors, including biological, psychological, and
problems and stress. sociocultural.
We observed a varion in the prevalence of Our study indicated that most of the respondents
alcoholism based on age. Results showed that confirmed that they have children in school. It can
highest prevalence of alcoholism was in the 36 – 75 be deduced that a significant number of respondent
years (40%) followed by the 26 – 35 age group have family responsibility. This may be the reason
(30%), then the group 22 – 25 (20%) and 18 – 21 why they find time to cool off at beer pallor, or

resort to alcohol intake as a mode of enjoyment and increase in incidence of liver cirrhosis, hypertension
pleasure. Similarly, majority of the respondents among the populace, hence abstinence still remain
confirmed that despite their family responsibility, the best preventive cure or better drink moderately.
they were still able to perform their social functions. In this present study, some of the respondents
This is an indication of great sense of responsibility indicated their intension of stopping alcohol
among the respondents which also point that most of someday. Our finding is consistent with a previous
the respondents drink for pleasure. report (Pender et al., 2002) which indicated that a
patient can plays an active role in initiating and
Our study indicates that the respondents go in to maintaining health promotion behaviors, as well as
alcoholism because of different reason; for pleasure, altering their personal lifestyle and environment.
peers pressure, due to frustration in life. Previous
report (Pender, 1975) indicates that certain Conclusion
perceptions and influences lead an individual to This study indicates that alcoholism is a public
commit or not commit to a plan of action to promote health problem in Sokoto State Nigeria.
health, factoring in immediate competing demands.
Similarly, Pender and Colleagues (2002) state that Recommendation and suggestion
an individual’s behaviors are driven by prior related In view of the menace of alcoholism in the society
health promotion behaviors, as well as personal as observed in this study, the following
factors, including biological, psychological, and recommendations are made; There is need to train
sociocultural. health workers to enable them offer health education
and counselling to alcoholics in Sokoto in particular
Our study indicated that a significant number of and Nigeria in general. There is need to intensify
respondents had no knowledge of the potential effect public awareness programme to educate members of
of alcoholism on their health. This might be a reason the community on the negative effect of alcohol.
why majority become alcohol dependent. There is need for enforcement of relevant legislation
dependence. Risk factors are co-relational and not to control the selling and consumption of alcohol in
necessarily casual because correlation does not the area.
imply causation. A risk factor causes a person or
group of people to be particularly susceptible to an References
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NY.


Original Research
SJMLS-2(1)-2017-013
Review on Laboratory Auditing in Histopathology Laboratory
*
Omorodion, N.T.1, 2, Achukwu P.U, Ebo N1
Department of Medical Laboratory Science, School of Basic Medical Sciences, University of Benin, Benin
City, Nigeria 1, Department of Medical Laboratory Science, Faculty of Health Sciences and Technology,
University of Nigeria, Enugu Campus, (UNEC) Nigeria 2.
*Corresponding Author: terry.omorodion@uniben.edu/ +234-813-674-2270
Abstract body that would monitor activities and support the

The concept of quality control, which is deeply nodal centers with operational and financial
rooted in most other disciplines of laboratory resources should also be established. Affiliation of
medicine, is relatively still young in histopathological the national coordinating body with similar
aspect of Laboratory Medicine. The concept of organizations with related activities worldwide will
quality assurance includes pre-analytical, analytical allow for implementation of evidenced –based best
and post analytical. The assessment of both practices.
accuracy and precision of performance is made
possible by external and internal quality assessment Keywords: Histopathology, Auditing,
and quality control scheme. There is a special focus Histopathology, Laboratory
on external quality assessment scheme that lacks
organization on a rational level in the country. Introduction
Laboratory auditing concerns primarily everyday
The concept of quality control, which is deeply
aspect of the work of the department and is a means
rooted in most other disciplines of laboratory
of providing feedback mechanism between the user
and the staffs of the Laboratory. A diagnostic
medicine, is relatively still young in
pathologist may wish to examine the following area histopathological aspect of laboratory medicine. The
of laboratory auditing. The audit process beings with concept of quality assurance includes pre-analytical,
the audit drawing up an audit checklist to comply analytical and post analytical. The assessment of
from quality system manual of the being audited. both accuracy and precision of performance is made
The auditor then checks compliance, non- possible by external and internal quality assessment
compliance against this checklist and write a report and control scheme (Kohn et al., 2000). There is a
of findings. The assessment system itself must be special focus on external quality assessment scheme
audited by some non-technical personnel, whereas
that lacks organization on a rational level in the
of the technical activities must be audited by a
country Laboratory auditing concerns primarily with
person with technical knowledge. In totality, it is
better to have series of smaller audit than have one
everyday aspect of the work of the department and is
large audit. Any abnormalities discovered in the a means of providing feedback mechanism between
course of auditing should be corrected immediately. the user and the staffs of the Laboratory (National
There is need for the establishment of zonal/nodal Patient Safety Goals, 2004). A Medical Laboratory
centers that would conduct/coordinate similar Scientist may wish to examine the following area of
activities in their respective regions. These centers laboratory auditing.’
may operate on a self-sustainable basis through
nominal subscription fees. There should also be (1) Request form: Are they easy to use? Are
Establishment of a program that would periodically
relevant details made available by the users?
evaluate the nodal centers. A central coordinating

For example, data of contact or the onset of From quality control to total quality
the disease would be useful in the case of management
request for widal serology. The terms Quality Control (QC), Quality Assurance
(QA) and Total Quality Management (TQM) are
(2) Specimen: Is the right sample received at defined in more ways than one. They differ from
appropriate time? Are the right investigations each other in the degree of process and
selected by the Clinician? It is necessary that organizational involvement, which is overall and
specimen coming to histopathology laboratory maximal in TQM. For all practical purposes, all
should be fixed immediately it is removed these elements should be focused on; generating an
from the body in fixative of choice. accurate histopathology report and enabling the easy
retrieval and review if needed over a defined time
(3) The number of request for each specific test period. A good quality histological section is the
should be properly documented or audited. starting point of an accurate histopathology report.
All the processes involved in generating the section
(4) The test record should be carried out may be grouped under the pre-analytical part. The
appropriately following standard procedure. analytical part concerns the interpretation of the
slide and making an accurate diagnosis. The post-
(5) Turnaround time for each request. The analytical part involves the generation and
turnaround time for each request should be transmission of the histopathology report,
followed strictly. storage/disposal of samples, slides and blocks and
proper retention of test result.
(6) Safety policies and procedure should be in
place in every histopathology laboratory. Pre-analytical phase
All processes involved up to the submission of
(7) Efficient use of staffs. Do senior staffs stained slides for investigation are placed under pre-
perform duties meant for the junior ones? analytical. Innovative models for the pre-analytical
Efficient use of staff should be put into phase also include aspects like patient satisfaction
consideration much more a smaller laboratory with the collection process, professional staff
than a bigger one. satisfaction with preparations made by the
laboratory towards sample collection and transport,
Quality control is traditionally applicable to three etc. (Hollensead et al., 2004).
phases of operation; the pre-analytical phase; the
analytical phase and the post-analytical phase (Barr, Various studies have shown that majority of errors
1999). The pre-analytical phase is related to sample made by the laboratory occurs in the pre- analytical
collection, transport, accession and processing. The phase (Wiwanitkit, 2001). The same challenge also
analytical phase is related to actually carrying out exists in the histopathology laboratory (Sharif et al.,
the test (manual/automated) and the activities that 2007). A lot has been written about necessity of
follow (transmission of results, storage/disposal of primary fixation and the selection of fixatives of
samples, maintenance of test data, and so on) choice for specific histopathology investigations. At
comprise the post-analytical part. When descriptive this juncture, it is worth restating that the duty to
reports are made, such an assessment becomes less ensure that documented guidelines containing
simple though not unachievable. The following is an pertinent information are made available at all points
overview of all the processes involved in the of specimen collection rests with the laboratory.
generation of a quality histopathology report. The Accurate patient identification by a unique
author's experiences in convening a small scale EQA laboratory number that is traceable to the specimen
program are also described. and report all through the process is of major
importance. Errors in this area are common but
avoidable. The author has found immense benefit in

using Bar Code technology to minimize errors in c. Usage of controls for routine and special stains
sample accession and identification. Similarly, daily as a routine is recommended. For routine
wrong identification of anatomic location as well as H & E staining, the laboratory may identify one
laterality of biopsy (right/left) are common errors tissue block with a good mixture of
that should be avoided. It would be worthwhile for haematoxyphilic and eosinophilic tissue
the laboratory to design its own "referral form" for (cervix, fibroadenoma, etc.) as a control.
histopathology and immunohistochemistry and Multiple slides may be cut and kept aside to be
make it accessible to all areas of sample collection. used as controls. The control slide should be
This form should provide space to record of the stained before the routine batch of slides and
relevant clinical data. It may be useful to insert the staining character should be compared with
check boxes for better clinician compliance. that of the previous day. By putting aside one
Communication with the clinician about the block for control, one avoids variation related
usefulness of properly filled forms may be needed. to tissue type. Similarly, known controls
Whenever clinical data is not provided, the (positive and negative) should be used for
laboratory should take the initiative to extract histochemical staining. A record of the staining
important data either from the treating physician or character should be maintained. The paraffin
clinic files. Other areas of error in the pre-analytical used for impregnation and embedding should
phase include lost specimens, inadequate sample be of good quality with an appropriate melting
volume, size, unrefined description, gross sampling, point.
wrong measurements, extraneous tissue (floaters)
(Zarbo et al., 2005), inappropriate d. Recording of the temperature of the paraffin
sections/inadequate serials, poor staining and bath, water floatation bath and slide warming
mounting quality, etc. table should be done on a daily basis.
Standardization of equipment should be carried
The following steps below are the relevant steps to out on a regular basis.
achieve pre-analytical phase properly.
a. Standard procedures for sample accession, e. The microtome should be of good quality,
identification, acceptance/rejection, gross usually rotary microtome is preferable. The
investigation and sampling and all the steps that microtome should be adjusted in other to ensure
follow must be documented. This standard consistency of section thickness (depending on
operating procedure should be documented in the microns). The importance of proper
simple language that can be understood by maintenance of the knife need not be reiterated.
everyone carrying out the process. The SOP The use of disposable blades is recommended.
should be available at the workplace and all
technical staff should be aware of its contents. f. Care should be taken to avoid artifacts through
improper processing, sectioning, staining and
b. Planned changing of chemicals used for mounting.
processing based on the number of tissues
passed through. This schedule will prevent g. Lastly, the label affixed on the stained slide
under processing and unnecessary rework and should be of a proper size and should not be
loss of tissue. The laboratory should record the allowed to cover the tissue sections. The
number of tissues passed through every day and identification should be legible and should
compulsorily change the chemicals once the ideally carry the name of the laboratory.
pre-determined limit is reached. The limit may Coding can be used in the identification of slide
be set based on the laboratory's experience. The (such as H for histology and C for cytology
same also applies to the deparaffinization, follow by the number.
staining, dehydration and clearing steps for
sections.

Analytic phase biopsies. The TAT of frozen sections should also be

Unlike in other disciplines of Laboratory Medicine, examined and potential bottle-necks should be
evaluation of analytical aspects in histopathology is eliminated. The retaining period for specimens has
not easy given the bias of the reports. Error continually been a subject of debate and national
detection and prevention in histopathology has been procedures for this are warranted.
transcribed about very often (Ramsay, 1999; Lesna,
1998; Hocking et al., 1997; Zuk et al., 1991 and External quality assessment
Owen and Tighe, 1975). Several modes of internal Certifying authorities insist that every laboratory
audits have been defined and recommended, should have some form of external quality valuation
(Association of Directors of Anatomic Surgical for all the tests done under its scope of activity
Pathology, 1991) each with their advantages. The (Assuring Quality of Examination Procedures,
following general recommendations are being made 2007). Organized EQA programs are available in
at this stage. other countries (CAP, UK-NEQAS). These are
either prohibitively cheap or not easily available in
1. For departments with more than one India. The Indian College of Pathology in
Histopathologist: collaboration with the Association of Pathologists of
 Random case review (blinded re-reporting North America (AIPNA) has initiated a program.
of random cases). There is a necessity to form and partake in a
 Intra-departmental consultation (evaluation structured EQA program on a provincial and
of selected cases by colleagues). national scale. The author has had personal
 Graded form of reporting. experience in coordinating a program that has
 Intra- and inter-departmental conferences. provided to NABL accredited laboratories for 3
years. The structure of this program is thorough
2. For laboratories with a single Histopathologist: along with relevant data from partaking laboratories.
 Random blinded review of reported cases
(precision check). The Inter-Laboratory Quality Assessment program
 External consultations (may need to be done for Histopathology (ILQA-HP) was launched in the
more often). year 2006 as part of the events of parent
 Review by experts. organization ILQA-Bangalore. The program was
 Participation in Continued Medical started with the instantaneous objective of providing
Education (CME) and Continuous external quality assessment in histopathology to
Professional Development (CPD) programs. NABL accredited laboratories in India, with the
lasting goal of including non-accredited laboratories
Post-analytical phase into the program. The scheme is divided into two
The archaic laboratory approach to the post- portions: the first assessing the pre-analytical
analytical phase involves report generation without aspects and the second assessing the analytical
transcription errors, report transmission/dispatch to aspects. There is an urgent need for such a
the right person(s), storing of reported material as programme in Nigeria. The Medical Laboratory
well as reported data and safe disposal of specimens Science Council of Nigeria (MLSCN) the regulator
thereafter. Newer models include billing issues, of Medical Laboratory Science Practice in Nigeria
patient safety issues (reporting of critical results), should be able to organize such EQA programs.
turnaround time (TAT) and overall customer
fulfillment (wait times) (Hollensead et al., 2004) etc. Conclusions
Monitoring of TAT is of vital significance and The audit process begins with the audit drawing up
laboratories should strive to achieve the goal of an audit checklist that complies with the quality
signing out the majority of cases within 48 hours of system manual of the being audited. The auditor
receipt of the specimen. The use of microwaves may then checks compliance, non-compliance against
assist in improving the TAT particularly for small this checklist and write a report of findings. The

assessment system itself must be audited by non- http://www.jcaho.org/accredited+organization/patie

technical personnel, whereas technical activities nt+safety.
must be audited by a person with technical Owen, D.A., Tighe, J.R. (1975). Quality evaluation
knowledge. In totality, it is better to have series of in histopathology. British Medical Journal;
smaller audit than have one large audit. Any non- 1:149-150.
compliance discovered in the course of auditing Ramsay, A.D. (1999). Errors in histopathology
should be corrected immediately. reporting: Detection and avoidance, A review.
Histopathology; 34:481-490.
Recommendations Royal College of Pathologists. (1998).
There is an urgent need for the establishment of Recommendations for the development of
zonal centers in assessing quality of assessment of Histopathology and Cytopathology External
every laboratory including that of Histopathology Quality Assurance Systems.
Laboratory. These centers may operate on a self- Sharif, M.Q., Mushtaq, S., Mamoon, N., Jamal, S.,
sustaining basis through nominal subscription fees. Luqman, M. (2007). Clinician's responsibility
Establishment of a program that would periodically in pre-analytical quality assurance of
evaluate what the laboratory is auditing. histopathology. Pakistani Journal of Medical
Establishment of a central coordinating body that Science; 23:720-723.
would monitor activities and support the nodal Wiwanitkit, V. (2001). Types and frequency of pre-
centers with operational and financial resources. analytical mistakes in the first Thai ISO
9002:1994 certified clinical laboratory: A 6-
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Original Research
SJMLS-2(1)-2017-014
Hepatitis A virus infection among HIV patients on highly active
antiretroviral therapy in Benin City, Nigeria.
Egbe, C.A.*1,2, Ogefere, H. O. 2 and Okwara, B.U.3
Medical Microbiology Unit, Medical Laboratory Services, University of Benin Teaching Hospital, Benin City,
Nigeria 1, Department of Medical Laboratory Science, School of Basic Medical Sciences, College of Medical
Sciences, University of Benin, Benin City, Nigeria 2, Department of Medicine, University of Benin Teaching
Hospital, Benin City 3.
Author for Correspondence*: egbeaye@yahoo.com/+234-813-674-2270
Abstract Keywords: Hepatitis A virus, HIV, HAART,

HIV patients have an elevated risk of HAV Infection, Nigeria.
infection. Against the background of paucity of
data on HAV infection among HIV patients on Introduction
HAART, this study was conducted to determine
Hepatitis A virus (HAV) is an ancient and
the prevalence of acute HAV infection among
ubiquitous human pathogen recovered previously
asymptomatic HIV patient on HAART. Blood
specimens were collected from 603 HIV patients
only from primates and is the sole specie of the
on HAART and screened for the presence of HAV genus hepatovirus, and existing in both enveloped
anti-IgM antibodies. CD4 count was carried out and non-enveloped forms (Drexler et al., 2015).
using standard techniques. A structured HAV is unique for its tropism for the liver among
questionnaire was used to collect data on other features (Drexler et al., 2015). It infects via
demography and risk factors. Age, gender and the feco-oral route and is shed in faeces as a naked,
CD4 count did not significantly affect the non–enveloped particle, but circulates in the blood
prevalence of HAV infection (p > 0.05). HIV cloaked in an envelope derived from host cell
patients that have used HAART for > 5years (p =
membrane (Freng et al., 2013).
0.0163), those that had no formal education (p <
0.0001), were divorced (p = 0.0274), lived in one
room apartment (p = 0.0294), used streams/rivers
Viral hepatitis and adverse effect of antiretroviral
as source of water (p < 0.0001) and consumed treatment have been reported as among the causes
fresh fish (p = 0.0404) had higher prevalence of of death among HIV infected patients (Lewden et
HAV infection. Not washing fruits before eating, al., 2015). Highly active antiretroviral treatment
not eating sea foods, not eating in restaurants, (HAART) has been reported to damage the liver in
travelling to HAV endemic countries, having a human immunodeficiency virus (HIV) infected
history of tattoo/scarification and practicing anal subjects (Wu et al., 2015). In patients with HIV
sex were significantly associated with HAV infection, HAV increases the severity of hepatitis
infection among HIV patients on HAART (p <
if there is pre–existing liver disease (Koziel and
0.05). An overall prevalence of 3.65% of acute
Peter, 2007).
HAV infection was observed among HIV patients
on HAART. The data presented will be useful in
Literatures abound on the co-infection of HIV and
the epidemiology and management of HAV hepatitis B virus (HBV), and HIV and hepatitis C
infection among HIV patients on HAART. virus (HCV), but few data are available for HIV
and HAV co-infection. Acute HAV infections

have been reported in India and Nigeria among using Hepatitis A virus IgM antibody Rapid test kit
apparently healthy individuals (Ogefere and Egbe, (Qingdao Hightop Biotech. Co., Ltd Shandong,
2016 and Rajani and Jais, 2013). Against these China) following the manufacture’s instructions.
backgrounds this study aims to determine the Briefly, 1.5µl of subject’s serum was added to the
seroprevalence of HAV among apparently healthy specimen area. This was followed by 2 drops of
HIV patients on HAART. The effect of socio– buffer. The result was read after 20 minutes. The
demography and some risk factors on the blood in the EDTA bottle was used for the
distribution of HAV infection among these patients estimation of CD4 count as previously described
was also investigated. using flow cytometry (Partec, GMBH, Germany)
(Egbe et al., 2015). Briefly, 20 µl of CD4PE
Materials and Methods antibody was placed into a Partec test tube and 20
Study population µl of well–mixed whole EDTA blood was added,
The study was carried out in University of Benin mixed and incubated in the dark for 15 minutes at
Teaching Hospital (UBTH), Benin City, Nigeria. room temperature. The mixture was agitated
A total of 603 HIV patients (consisting of 171 during incubation every 5 minutes. To the mixture
males and 432 females) were recruited for this was added 800µl of CD4 buffer and mixed gently.
study. The HIV patients were attending HIV clinic This was plugged to the counter for counting.
and were all on highly active antiretroviral therapy
(HAART) regimens. The regimens for HAART Statistical analysis
are divided into first line, alternate first line and The data were analyzed with the Chi square (X2)
second line drugs. The first line HAART regimens test and odd ratio analysis using the statistical
were further sub divided as follows: zidovudine, software INSTAT(R) (Graph Pad Software Inc., La
lamivudine and nevirapine, or combivir (consisting Jolla, USA).
zidovudine, lamivudine) and liponavir/ritonavir),
or combivir and efavirenz, or combivir and Results
abacavir, or abacavir, lamivudine and nevirapine. A total of 22 (3.65%) out of the 603 apparently
The second line HAART regimen entails any of healthy HIV patients on HAART were seropositive
the following combinations: abacavir, lamivudine for HAV infection. Gender, age and CD4 count did
and liponavir/ritonavir, or zidovudine, lamivudine not significantly affect the seroprevalence of HAV
and liponavir/ritonavir, or stavudine, lamivudine infection among HIV patients. The seroprevalence
and liponavir/ritonavir, or abacavir, lamivudine of HAV decreased from 4.4% among HIV patients
and aluvir. who have used HAART for ≤ 1year to 0.59%
among HIV patients that have used HAART up to
A structured questionnaire was used to collect data 4 years, and increased to 6.49% among HIV
on demography and possible risk factors. Informed patients that have used HAART for ≥ 5years. The
consent was obtained from all patients or their seroprevalence of HAV was significantly (p =
parents/guardians in case of children. This study 0.0163) affected by duration of HAART used
was approved by the Ethics and Research (Table 1). HIV patients with no formal education
Committee of UBTH. (p < 0.0001), divorced (p = 0.0274) and lived in
one room apartment (p = 0.0294) had higher
Specimen collection/processing: seroprevalence of HAV infection (Table 2).
From each patient, 10ml of blood was collected
and dispensed in 5ml amounts into ethylene Similarly, HIV patients that used streams/rivers as
diaminetetra acetic acid (EDTA) and plain source of water (p < 0.0001), who do not always
containers. This was mixed and labeled. The blood wash their fruits before eating (p = 0.0116), who
in the plain container was allowed to clot and the do not eat sea foods (p = 0.0003), who eat fresh
serum was obtained after centrifugation. The fish (p = 0.0404), and those who do not eat in
serum was used to detect HAV IgM antibodies restaurants (p = 0.0113) had higher prevalence of

HAV infection (Table 3). Travelling to HAV 21.311; p = 0.0026) and practicing anal sex (OR =
endemic countries (OR = 16.794 95% CI = 5.175, 22.776 95% CI = 4.760, 108.99; p < 0.0001) were
54.502; p < 0.0001), having a history of significantly associated with HAV infection
tattoo/scarification (OR = 6.573 95% CI = 2.02% among the HIV patients (Table 4).
Table 1: Seroprevalence of HAV in relation to age, gender, CD4 Count and duration of HAART usage
Characteristics No. tested No. positive OR 95% CI p- value
(%)
Gender
Male 171 9(5.26) 1.791 0.751,4.271 0.2759
Female 432 13(3.01)
Age (Year)
2 – 11 55 1(1.82) 0.4147
12 – 21 44 1 (2.27)
22 – 31 66 2 (3.03)
32 – 41 183 6 (3.28)
42 – 51 159 7 (4.40)
52 – 61 61 5(8.20)
CD4 count (cells/ µL)
<200 103 5(4.85) 1.450 0.522,4.023 0.6684
> 200 500 17(3.40)
Duration of HAART use
(years)
<1 45 2(4.44) 0.0163
2 56 1(1.78)
3 73 1(1.37)
4 167 1(0.59)
>5 262 17(6.49)

Table 2: Effect of socio-economic status on the seroprevalence of HAV

Characteristics No. tested No. positive (%) p- value
Level of education
No formal 32 6(18.75) <0.0001
Primary 173 4(2.31)
Secondary 236 5 (2.12)
Tertiary 162 7(4.32)
Marital status
Single 226 4(1.77) 0.0274
Married 277 13(4.69)
Divorced 23 3(13.04)
Widow 77 2(2.60)
Occupation
Artisans 63 4(6.35) 0.6863
Businessmen/women 112 4(3.57)
Civil servants 152 5(3.29)
Traders 276 9(3.26)
Location
Urban 89 2(2.25) 0.7196
Sub-urban 116 5(4.31)
Rural 398 15(3.77)
Accommodation type
One room 58 6(10.34) 0.0294
One room self-contain 61 3(4.91)
Two rooms 164 7(4.27)
Two rooms self-contain 142 3(2.11)
Flat 178 3(1.69)

Table 3: Prevalence of HAV infection in relation to source of water and feeding habits
Characteristics No. tested No. Positive OR 95% CI p- value
(%)
Source of water
Rain/well 9 2(22.22) < 0.0001
Stream/river 11 4(36.36)
Borehole 572 16(2.80)
Packaged water 11 0(0.00)
Always wash fruits before
eating
Yes 596 20(3.36) 11.520 2.105,63.045 0.0116
No 7 2(23.37)
Eating salads/raw vegetables
Yes 584 20(3.42) 0.301 0.065,1.395 0.3158
No 19 2(10.53)
Eating sea foods
Yes 599 20(3.34) 28.950 3.877,216.17 0.0003
No 4 2(50.00)
Types of sea foods consumed
Crayfish 161 3(1.86) 0.0404
Fresh fish 251 16(6.37)
Crabs 24 1(4.17)
Prawns 27 1(3.70)
Water snails 136 1(0.74)
Eating fish from fish ponds
Yes 541 18(3.33) 0.499 0.163,1.525 0.3760
No 62 4(6.45)
Eating in restaurants
Yes 561 17(3.03) 4.324 1.511,12.376 0.0113
No 42 5(11.90)

Table 4: Risk factors associated with HAV seroprevalence

Characteristics No. tested No. Positive OR 95% CI p- value
(%)
Travelling outside the country
Yes 37 3(8.11) 2.540 0.716,9.012 0.2979
No 566 19(3.36)
Travelling to HAV endemic
countries
Yes 15 5(33.33) 16.794 5.175,54.502 < 0.0001
No 588 17(2.89)
History of blood transfusion
Yes 232 4(1.72) 0.344 0.115, 1.030 0.0768
No 371 18(4.85)
History of tattoo/scarification
Yes 23 4(17.39) 6.573 2.027,21.311 0.0026
No 580 18(3.10)
Practicing anal sex
Yes 7 3(42.86) 22.776 4.760,108.99 < 0.0001
No 596 19(3.19)
Discussion seroprevalence of 5.8% of HAV among HIV

HIV-infected persons are at risk of infection with patients was reported by Fonquerine et al. (2001).
one or more of the hepatitis viruses (Tedaldi et al., Seven of the 9 subjects used in that study (Fonqerine
2004). Hepatitis A virus (HAV) infection is the most et al., 2001) were on antiretroviral therapy but the
common cause of acute viral hepatitis worldwide study did not mention the prevalence of HAV
(Wang et al., 2013). HIV patients have an elevated among such HIV patients.
risk of HAV co-infection and previous studies have
shown that 20% - 70% of HAV–positive patients The duration of HAART usage significantly affected
have evidence of prior HIV infection (Crum- the seroprevalence of acute HAV infection among
Cianflone et al., 2011). Viral hepatitis and HIV patients in this study (p = 0.0163). HAART
antiretroviral agents have been reported to be among promotes the reconstitution of the immune system of
the cause of death among HIV patients (Lewden et HIV infected persons (Akinbo et al., 2013 and
al., 2015). Against the background of paucity of data Willemot and Klein, 2004), with those who have
on the prevalence of HAV infection among HIV used the therapy for 5 years or more having the
patients on HAART, this study was conducted. highest prevalence, followed by those who used
HAART for 1year or less. We could not adduce any
The seroprevalence of acute HAV infection reason for this.
observed in this study was 3.65%. This is
comparable with the 3.1% reported among The finding that there was no significant difference
antiretroviral therapy (ART) naive patients in Dar es in the seroprevalence of HAV based on gender
Salaam, Tanzania (Nagu et al., 2008) but higher agrees with a previous report (Malaty et al., 1996).
than 0.6% in Brazil (Pavan et al., 2003) and 1.5% HIV patients with no formal education have
reported among apparently healthy non–HIV significantly higher prevalence of HAV. Prevention
patients in Benin City, Nigeria (Ogefere and Egbe, of HAV is based on maintaining good hygienic
2016). No data on the seroprevalence of HAV practices amongst other factors (Fonquerine et al.,
among HIV patients on HAART was found in local 2001). People with no formal education may have
literature. The treatment status of the HIV patients poor hygiene practice and this may explain the
used by Pavan et al. (2003) was not stated. A findings in this study. Similarly, HIV patients that

are divorced, and those living in one room apartment eat sea foods of which 2 were seropositive for HAV
have significantly higher prevalence of HAV infection.
infection. Low socio–economic status has been
associated with Helicobacter pylori infection It has been report that travelers from developed
(Hussain, 2011). H. pylori and HAV are diseases countries to region of the world where HAV is
that are associated with poor hygiene and low endemic are at an increase risk of contracting HAV
economic status. Therefore, the high prevalence of infection (Steffen, 1985). Nigeria is regarded as an
HAV among those with low socio–economic status HAV endemic country (Wasly et al., 2006 and
(no formal education, divorced, and living in one Costa–Mattioli et al., 2003). In this study, HIV
room) may also be connected with poor personal and patients who travelled to other HAV endemic
environment hygiene. This may explain the findings countries had significantly (p<0.0001) higher
in this study. prevalence (33.33%) than their counterparts who did
not (2.89%) and travelling to HAV endemic
Consumption of contaminated foods and water is a countries was associated with HAV infection. The
common source of HAV infection and waterborne HAV endemic countries in this study include Indian,
transmission predominates in developing countries the Middle East and other African countries.
(CDC, 2000). In this study, those who used streams
or rivers as source of water, those that do not always History of tattoo/scarification was significantly
wash fruits before eating, those that eat fresh fish associated with HAV infection among HIV patients
and those that do not eat in restaurants have on HAART (p = 0.0026). This is in agreement with
significantly higher prevalence of HAV infection (p a recent study on HAV infection among apparently
= 0.0001, 0.0116, 0.0404 and 0.0113 respectively). healthy individuals in our locality (Ogefere and
In our environment where HAV is reportedly Egbe, 2016). In Ogefere and Egbe (2016) study, it
endemic (Wasly et al., 2006 and Costa–Mattioli et was opined that since tattoo and body piercing are in
al., 2003), environmental and human wastes may be vogue, young adults living in resource–poor regions,
dumped into streams and rivers as a result of lack of such as Nigeria, may resort to using unsterilized
waste management facilities. This may explain why materials for this purpose. In developed countries,
people that use stream or rivers have higher HAV infection is more among homosexual and
seroprevalence of HAV infection. The level of poor travelers to endemic countries as well as from
personal hygiene may explain the higher prevalence consumption of contaminated foods (Vaughan et al.,
among those that do not always wash fruits before 2013 and Carvalho et al., 2011). All participants in
eating. Transmission of HAV infection through the this study had heterosexual orientation and all of the
faecal–oral route as a result of insufficient sanitation seven that indicated that they practice anal sex were
and poor hygiene conditions that favours the females. Practicing anal sex was significantly
pollution of water and foods especially shellfish, has associated with acute HAV infection among HIV
been noted (Steffen, 1985). This may explain the patients (p < 0.0001). This may indicate that anal
finding that HIV patients that eat fresh fish have sex irrespective of the gender practicing it maybe a
higher prevalence of HAV. Poor personal hygiene, risk factor for HAV infection. Further studies
improperly cooked meal and consumption of (molecular analysis) is needed to determine if the
contaminated water may explain why people who do genotype recovered from those practicing anal sex in
not eat in restaurant have higher seroprevalence of our environment is the same as those recovered from
HAV. men who had anal sex with men.
It was observed that not eating of sea foods In conclusion, an HAV seroprevalence of 3.65%
prevented HIV patients on HAART from having among HIV patients on HAART was observed in
HAV infection (p=0.0003). The reason for this is this study. HIV patients that have been on HAART
unclear. However, it is important to note that only 4 for 5 years or more, have no formal education,
HIV patients on HAART indicated that they do not divorced, living in one room apartment using

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Original Research
SJMLS-2(1)-2017-015
Malaria in Sokoto: A Case Study of 1 Brigade Medical Centre.
Mohammad, S. 1, Igbineweka, O.O. 2, Yahya, A.1., Ige, J. 3, Uche, V. N. 4, Ikpeama, O.J. 1, Ogwuegbu, J.U. 5
1 Brigade Medical Centre, Sokoto 1, Department of Periodontology and Community Dentistry, University
College Hospital, Ibadan 2, Department of Public Health University of Nigeria 3, Department of Public Health
Imo State University, Owerri 4, Department of Medicine, Imo State University, Owerri 5
Author for Correspondence: ikpeama35@gmail.com/+234- 806-261-9025
Abstract Saharan Africa. Malaria is one of the three killers

The aim of this study was to determine the among communicable diseases in Africa (Ahmed et
prevalence of malaria in Sokoto, North Western
al., 2014). In Southern Nigeria, at least 35,000
Nigeria. The data was collected from the health
children die annually from direct effects of malaria
facility daily outpatient department register. The
alone (FMH, 2005b). Despite frantic efforts at
malaria testing was carried out according to World
Health Organization (WHO, 2011) standard using eradicating malaria, about 40% of the world
microscopy and malaria rapid diagnostic tests population in 91 countries continue to be plagued by
(RDTs). The test is an immune chromatographic this disease (UNAIDS, 2010).
antigen- detection tests technique. The research
was carried out between June and October 2016. Malaria is endemic throughout Nigeria with
Out of 4,261 clients tested within the period, 2573 seasonal variation in different geographic zones of
(60.4%) were confirmed with malaria infection. the country. More than 90% of the total population
Children less than 5 years had a prevalence of
is at risk of malaria and at least 50% of the
18.1% while children that are five years and above
population suffers from at least one episode of
had a prevalence of 42.4%. There were more cases
of malaria among female patients 1142(44.4%). In
malaria each year. Beyond the impact on children
the cases on malaria, the calculated chi-square and pregnant women, it affects the general
(χ2=1642.3, is greater than tabulated χ2 0.05=11.07 population (FHM, 2005b). The disease is the
at df=5, p<0.05). Community participation and health commonest cause of outpatient attendance across all
education strategies promoting awareness of age groups with about 66% of clinic attendance due
malaria and the importance of control measures to malaria (FMH, 2000) and thus constituting a great
should be done. The community should be educated burden on the already depressed economy.
on the prevalence rate of the disease, its danger to Epidemiological patterns of malaria are widely
health and how it the disease can be prevented.
different from one place to another (Himeiden et al.,
2005). Specific data of a place collected can help in
Introduction
the making of a tailor-made design of improved
Malaria remains a major public health concern
programme for strategic malaria control for a
worldwide, causing 216 million infections and
particular location. There are available effective
approximately 655,000 deaths in the year 2010
low-cost strategies for the treatment, prevention and
(WHO, 2011). Of the 91 percent of malaria–related
control of malaria. But any attempt to prevent or
deaths are in Africa, 86 percent of victims are
control a disease such as malaria in any area or in a
children aged under five (Ahmed et al., 2014).
locality should first of all be preceded by an
Malaria is responsible for a significant number of
extensive evaluation of the magnitude of the
deaths in endemic countries particularly in sub

prevailing situation. Malaria has been the subject of b. What is prevalence of malaria cases among
study in many parts of Nigeria. children < 5year
Statement of Problem c. What is the number of malaria case among
Malaria is responsible for a significant number of female and male in general patients and
deaths in endemic countries particularly in sub children less than five years.
Saharan Africa. About 216 million infections and
approximately 655,000 deaths were recorded Hypotheses
worldwide in the year 2010 (WHO, 2011). About 91 a. There is no case of malaria in the facility.
percent of malaria–related deaths are in Africa with b. There is no malaria case among children
86 percent of victims being children aged under five <5years
(Ahmed et al., 2014). Malaria is one of the three d. There is no malaria case among female and
killers among communicable diseases in Africa male in general patients and children less
(Ahmed et al., 2014). The News Agency of Nigeria than five years.
recalls that the World Health Organization
designated April 25 every year to sensitize the Materials and Methods
global community about Malaria and efforts being Study area and the population
made to eradicate the disease. In Sokoto, there had 1 Brigade Medical centre, Gingiya barracks, Dange
been a number of researches on malaria (Abdullahi Shuni LGA in Sokoto South senatorial zone was the
et al., 2009) but there is probably no published study area. By the virtue of its origin, the state
epidemiological information concerning the study comprises mostly Hausa/Fulani and other groups
area. A comprehensive study of malaria situation of such as Gobirawa, Zabarmawa, Kabawa, Adarawa,
the locality is expected to provide base-line Arawa, Nupes, Yorubas, Igbos and others. The
information, which will be useful in the effective Sokoto township is in dry Sahel surrounded by
formulation of control measures, which could thus sandy terrain and isolated hills. Rainfall starts late
help move the locality towards achieving the that is in June and ends in September but may
Millennium Development Goals (MDGs). sometimes extend into October. The average annual
rainfall is 550 mm with peak in the month August.
Aims and objective The highest temperatures of 45°C during the hot
The aim of this study was to determine the season are experienced in the months of March and
prevalence of malaria in Sokoto, North Western April. Harmattan a dry, cold and dusty condition is
Nigeria. experienced between the months of November and
February (Udo and Mamman, 1993).
Significance of the study
Results of the study would reveal the prevalence of Ethical approval
malaria in this part in Sokoto metropolis. Ethical clearance was obtained from the Ethical
Specifically, result of the study would be significant Committee of the 1 Brigade Medical Centre,
to adults (male /female), public health officers, Ginginya Barrack, Sokoto.This study was conducted
health counselors, health educators, curriculum in accordance with the Declaration of Helsinki.
planners, medical allied personnel and researchers in
assessing the prevalence of malaria disease and Sample size
initiating preventive measures among inhabitants The sample size was the number of outpatient
would help prevention programs succeed in the attending the facility between the months of June to
populace in Sokoto metropolis. October 2016.
Research Questions Method of Data collection

a. What is prevalence of malaria case in the The data was collected from the health facility daily
facility outpatient department register. The malaria testing
was carried out according to World Health

Organization (WHO,2011) standard using Method of data analysis.

microscopy and malaria rapid diagnostic tests Data collected were analyzed using descriptive
(RDTs). The rapid diagnostic test is an immune statistic of frequency count, normative percentage
chromatographic antigen- detection tests was the and grand mean; as well as inferential statistics of
technique used in the course of research in a period chi-square (χ2). The level of significant was fixed at
of June to October 2016. ≤0.05. Appropriate degrees of freedom were worked
out.
Results
Table 1: Malaria cases confirmed and treated in facility between the month of June to October 2016.
Month Male Female Monthly Total
June 130 143 273
July 136 172 308
August 311 386 697
September 250 315 565
October 315 415 730
Total 1142 (44.4%) 1431 (55.6%) 2573
χ2=1642.3, χ2 0.05=11.07 at df=5, p<0.05
There were more cases of malaria among female month. On the prevalence of malaria, the calculated
patients 1142 (44.4%). Female subjects had the chi-square (χ2=1642.3, is greater than tabulated χ2
highest number 415 cases in October and male 0.05=11.07 at df=5, p<0.05). Therefore, the null
highest of 315 cases. The lowest cases of malaria hypotheses are rejected and conclusion drawn that
among the male occurred in the month of June 130 there is significant difference among male and
while that of the female is 143 cases in the same female gender on the case malaria disease.
Table 2: Malaria cases confirmed and treated in the health facility among patients above 5 years
between the months of June to October 2016.
June 70 109 179
July 73 135 208
August 189 303 492
September 166 249 415
October 190 321 511
Total 688 (38.1%) 1117 (61.9%) 1805
χ2=1269.2, χ2 0.05=11.07 at df=5, p<0.05
There were more cases of malaria among female in the same month. In the cases on malaria, the
patients 1117(61.9%). Female subjects had highest calculated chi-square (χ2=1269.2, is greater than
number 321 cases in October and male had the tabulated χ2 0.05=11.07 at df=5, p<0.05). Therefore,
highest of 190 cases in same month. The lowest the null hypotheses were rejected and conclusion
cases of malaria among the male 70 occurred in the drawn that there is significant difference among
month of June while that of the female is 109 cases male and female gender on the case malaria disease.

Table 3: Malaria cases confirmed and treated in the health facility among under 5 children between the
month of June to October 2016.
June 60 34 94
July 63 37 100
August 124 83 207
September 84 66 150
October 125 94 219
Total 456 (59.2%) 314 (40.8%) 770
χ2=457.7, χ2 0.05=11.07 at df=5, p<0.05
There were more cases of malaria among male same month. On the prevalence of malaria based on
children that are under the age of 5 years gender, the calculated chi-square (χ2=457.7, is
456(59.2%). Male had highest number 125,124 greater than tabulated χ2 0.05=11.07 at df=5,
cases in October and August respectively. The p<0.05). Therefore, the null hypotheses were
female had the highest malaria cases of 94 and 83 in rejected and conclusion drawn that there is
October and August respectively. The lowest cases significant difference among male and female
of malaria among the male 60 occurred in the month gender on the case malaria disease.
of June while that of the female is 34 cases in the
Table 4: Cases of malaria treated in the health facility between the month of June and October 2016
Month Cases among % of the Cases of % of Total % of Total number of
<5 subjects < 5 malaria subjects ≥5 number of subjects subjects that used
and have among that have cases of treated for facility
malaria subjects ≥5 malaria malaria malaria
June 94 15.9% 179 30.2% 273 46.1% 592
July 100 15.7% 208 32.6% 308 48.3% 638
August 207 18.1% 492 43.0% 697 60.9% 1144
September 150 17.4% 415 48.0% 565 65.4% 864
October 219 21.4% 511 49.9% 730 71.4% 1023
Total 770 18.1% 1805 42.4% 2573 60.4% 4261
The health facility had the highest cases of malaria Discussion

in October in which 71.4% of the treatment done in Malaria is the leading cause of morbidity in Nigeria
the health facility included malaria followed by most especially in North West of Nigeria. The result
September 65.4%, August 60.9%, July 48.3% and shows a general prevalence of malaria case from
the least of 46.1% in June. The facility had the June-October 2016 of 60.4%. It can be described as
highest cases of malaria among patients that are very high. The result corroborates the assertion
5years and above in October 511(49.9%). The according to the Acting Secretary of the FCT Health
facility had the highest cases of malaria among and Human Services Secretariat, Alice Odey-Chu
patients that are < 5years in October 219(21.4%). that the average Malaria prevalence is 71 per cent in
The facility had the highest cases of malaria among the country and about 66 per cent in the FCT. Odey-
the patients in the months of October and lowest in Chu said this at a ceremony to mark the 2016 World
June 2016. The general prevalence of malaria case Malaria Day in Abuja. The News Agency of Nigeria
from June-October 2016 is 60.4% while that of recalls that the World Health Organization
children < 5 years was 18.1% while patients that are designated April 25 every year to sensitize the
five years and above is 42.4%. global community about Malaria and efforts being
made to eradicate the disease. The theme for the

2016 World Malaria Day was: “End Malaria for months of age and was strongly correlated with
Good,” with the slogan: “It Is possible.” “Nigeria parasitaemia (OR = 2.3, 95% CI: 1.8-2.5). Net
and Democratic Republic of Congo are the two ownership (mainly untreated) was 225/2,532 (8.9%).
countries that recorded up to 35 per cent of malaria
deaths as at 2015. The disease, she said, has serious There were more cases of malaria among male
impact on the most vulnerable people in society children that are under age 5 years 456(59.2%).
which include pregnant women and girls, children, Male had the highest number 125,124 cases in
less than five years, Internally Displaced Persons October and August respectively. The female had
(IDPs) and the homeless, among others. Pregnant the highest malaria cases of 94 and 83 in October
women have two to three times at a higher risk of and August respectively. The lowest cases of
suffering from malaria. This increases their risks of malaria among the male 60 occurred in the month of
miscarriages, still birth, premature births, low birth June while that of the female was 34 cases in the
weight and anaemia during pregnancy. same month. In the cases on malaria, the calculated
chi-square (χ2=457.7, is greater than tabulated χ2
The prevalence of malaria infection in children less 0.05=11.07 at df=5, p<0.05). Therefore, the null
than 5 years observed in this study was 18.1%. This hypotheses were rejected and conclusion drawn that
result is higher than a similar research in Eastern there is significant difference in the prevalence of
Nigeria which reported a 17% prevalence rate malaria based on gender. Our finding is at variance
(Anumudu et al., 2006). Our observed prevalence is with a previous report (Gilles and Warrell, 1993)
however lower than that conducted in Azia, which indicated that there is no scientific evidence
Anambra State which indicated a 76% prevalence. to prove the effect of gender on the prevalence of
This result is higher than the 40% annual prevalence malaria.
rate found in Nigeria reported by Federal Ministry
Health (2005). The higher prevalence of malaria The higher prevalence rate in the different age
among children under 5years of age is in line with groups could just be by chance. The prevalence of
several studies (WHO, 2005; Umar and Hassan, malaria infection in patients that are five years and
2002). Eseigbe and Colleagues (2013) in a related above is 42.4%. There were more cases of malaria
research reported that out of the 730 febrile children among female subjects 1117(61.9%). Female
assessed, 411 (56.3%) had malaria parasitemia with subjects had the highest number 321 cases in
densities of 1+, 2+ and 3+ in 301(73.2%), 90(22%) October and male had the highest of 190 cases in
and 20(4.8%) children respectively. Majority were same month. The lowest 70 cases of malaria among
males (476, 65.2%), aged = 2 years (409, 56%) and the male subjects occurred in the month of June
in the upper social classes (497, 68.1%). Similarly, while that of the female is 109 cases in the same
Roberts (2015) in a research in Uganda involving a month. In the cases on malaria, the calculated chi-
total of 3,972 children who were tested for malaria. square (χ2=1269.2, is greater than tabulated χ2
Of the children tested, 1,725 tested positive, 0.05=11.07 at df=5, p<0.05). Therefore, the null
resulting in an observed prevalence of 43.4%. Also, hypotheses was rejected and conclusion drawn that
Wolkon et al. (2006) in a community-based baseline there is significant difference among male and
cross-sectional survey conducted in three districts in female gender on the case malaria disease. Houben
Togo in September 2004 as part of a et al. (2013) reported that in a total of 497
multidisciplinary evaluation of the impact of the inhabitants representing approximately 90 percent of
Togo National Integrated Child Health Campaign, the population participated: a quarter of the study
investigted 2,532 enrolled children from 1,740 group carried malaria parasites exclusively
households. A total of 62.2% (1,352/2,172) of the Plasmodium falciparum (P. falciparum)-representing
subjects were parasitemic and 84.4% (2,129/2,524) a P. falciparum parasite rate (PfPR) of 24.5%. Also,
were anaemic (haemoglobin < 11 g/dL). Moderate- 53/138 in the age group of 2 to < 10 years old
to-severe anaemia (< 8.0 g/dL) was found in 21.7% children tested positive for P. falciparum
(543/2,524), with a peak prevalence in children 6-17 representing a PfPR2-10 value of 38.4%. Higher

cases of malaria was also reported by Eseigbe and The research study has revealed the presence of
Colleagues (2013) in a related research reported that malaria infection in 1 Brigade Medical Centre
out of the 730 febrile children assessed, 411 (56.3%) Sokoto State, Nigeria. The overall infection rate is
had malaria parasitemia with densities of 1+, 2+ and high.
3+ in 301(73.2%), 90(22%) and 20(4.8%) children
respectively. Majority were males (476, 65.2%). Recommendations
1. Sanitary measures aimed at reducing the
The malaria infection among female subjects was breeding sites of mosquitoes such as filling and
1142(44.4%). Female had highest number 415 cases draining areas of water should be done.
in October and male highest of 315 cases. The 2. Larvicides should be applied to the gutters and
lowest 130 cases of malaria among the male drainages in front and around the houses in the
occurred in the month of June while that of the area.
female is 143 cases in the same month. In the cases 3. Community participation and health education
on malaria, the calculated chi-square (χ2=1642.3, is strategies promoting awareness of malaria and
greater than tabulated χ2 0.05=11.07 at df=5, the importance of control measures should be
p<0.05). Therefore, the null hypotheses were done. The community should know the
rejected and conclusion drawn that there is prevalence rate of the disease, its danger and
significant difference among male and female how it can be prevented.
gender on the case malaria disease. 4. Practical and intensive home visits should be
done by health workers to ensure that people
Clearly this study was conducted in a small make use of insecticide-treated nets. They may
geographical area, nonetheless it should be noted the have to check their rooms to see if the nets are
study was carried out during the raining season and hung.
at a time of high agricultural activity which include 5. Incentives should be giving to people that have
planting which is associated with bushes close to the clean environment that will prevent the
houses of subjects, and harvesting which breeding of mosquitoes and the people that
predisposes one to mosquito breeding and bite hence always make use of their insecticide-treated
guarantee a high transmission rate for malaria. The nets. This will bring competition within the
core finding of this study identifies an intermediate community and there will be overall reduction
endemicity for malaria in this region in contradiction of prevalence of malaria. This should be done
to prevailing assumptions (Tidi , Akogun,2005; Tidi quarterly.
et al., 2009). It is hoped that our study is a
contribution to the epidemiological data for malaria Suggestion for Further study.
in this region, after all mathematical modelling of
disease burden relies on robust baseline data (Snow 1. Knowledge of malaria risk factors and
et al.,2005). preventive measures
2. Knowledge of attitude and practices that
Limitation of The Study promote malaria fever.
The study was conducted using one health Centre, 3. Treatment and management module practices
though located in the strategic location of the town. of malaria case in different health facility in
This result may reflect what is happening in other Sokoto.
similar health Centre in the city. This base-line data
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Review Article
SJMLS-2(1)-2017-016
The Use of Antibody as Drug Carrier in Cancer Chemotherapy
Oyeniyi, Y.J.*1 and Abdulsamad, A 1.
Department of Pharmaceutics and Pharmaceutical Microbiology,
Faculty of Pharmaceutical Sciences, Usmanu Danfodiyo University Sokoto 1.
Author for Correspondence*: drjimioyeniyi@gmail.com/+234-803-347-2945
Abstract availability of suitable linkers, vital for successful

Antibodies are large Y-shaped immunoglobulins, attachment of the cytotoxic agent to the antibodies.
produced by plasma B cells in response to invading Despite this drawback, the use of ADC for cancer
pathogen termed antigen. They are used by the treatment will become more relevant as more
body defence (immune) system to recognize and researches unfold the best production methods and
neutralized specific antigen. Antibodies are also conditions.
considered as gift of nature without which body is
defenceless. Antigens are substances capable of Keywords: Antibodies, Linkers, Cytotoxic agent,
triggering an immune response. Cancer cells are ADC, Cancer chemotherapy.
also known to be associated with specific antigens
which are over expressed preferentially. These Introduction
antigens are now exploited pharmaceutically to
Cancer is the name given to a collection of related
develop new class of cancer chemotherapy termed,
diseases. In all types of cancer, some of the body’s
antibody drug conjugate (ADC). The aim of this
cells begin to divide and proliferate on their own
study was to review the various applications of
antibodies as drug delivery vehicles in cancer without stopping and may spread into surrounding
chemotherapy and their therapeutic benefits. For the tissues or organs (Varricchio, 2004). A cancer cell is
conventional chemotherapy to remain clinically an abnormal cell that disregards the normal rule of
relevant, the adverse drug reaction associated with cell division, growth, proliferation, differentiation
these cytotoxic agents must be curtailed. and death. And in most cases cancer cell develops
Incorporating by conjugating known cytotoxic agents its own autonomy and rules leading to uncontrolled
with antibodies that can recognize specific surface growth and proliferation (Hanahan and Weinberg,
tumour associated antigens is one of the possible
2000)
strategies that are being exploited to a great
success clinically today. The use of antibodies as
drug carriers (antibody-drug conjugates) enhances
Cancer arises from host cell via neoplastic
specificity, selectivity thereby improving transformation or carcinogenesis i.e. deregulation of
pharmacokinetic profile, by decreasing the volume genes that regulate cell growth. Cancer is clonal in
of distribution and prolonging the distribution and origin, that is to say it originates from a single
elimination phases. The reduced toxicity and abnormal cell with altered DNA sequence; however,
improved therapeutic outcome, has led to an it is a multi-gene, and muti stage disease.
increase research interest and are of growing Uncontrolled proliferation of a single abnormal cell
significance in cancer therapy, as evidenced by may be followed by a second mutation leading to the
increasing numbers of antibodies-based
aberrant stage. However, successive and continuous
pharmaceuticals been approved for oncologic
rounds of mutation and proliferation of these cells
indications by the FDA. However, the production of
antibodies drug conjugates is limited by the

results in the formation of tumour mass (Scott et al., 2012).
Figure 1: Clonal expansion of Cancer.
Cancer is among the most common causes of diseases characterized by unregulated cell
morbidity and mortality worldwide, with an proliferation that can arise from contributions from
estimated 14 million new cases and 8 million deaths numerous causative factors, including nutrition,
in 2012; projected to rise by at least 70% by the year genetic and environmental (Chabner and Roberts,
2030 (Ferlay et al., 2015). An ever-increasing 2005). Cancer alone caused over 8 million deaths
cancer burden is expected in the coming years, worldwide in 2013 and has moved from the third
particularly in low and middle income countries leading cause of death in 1990 to the second leading
(LMIC), like Nigeria, with over 20 million new cause behind cardiovascular disease in 2013
cancer cases expected annually as early as 2025 (Lozano et al., 2013; Murray and Lopez 1997).
(Bray, 2014 and Forman et al., 2013).
The incidence rates have increased in most countries
Cancer poses a major threat to public health since 1990. The trend if not addressed quickly, may
worldwide, and despite repeated campaigns to defeat become a serious threat to many developing nations
cancer, such as Nixon’s War on Cancer, all have with poor health systems characterized with ill-
failed, because cancer is not a single and simple equipped and trained specialist oncologist to deal
disease. In fact, it is a collection of highly complex with the complex and expensive cancer treatments.

Figure 2: Global Cancer incidence

Figure 3: Global Cancer mortality.
The current strategies to combat cancer depend on The goal of cancer chemotherapy is to selectively
the type, location and grade of the cancer as well as and completely kill the cancerous cells using
the patient's health and preferences. These strategies cytotoxic agents, without negatively affecting
include surgery, chemotherapy, immunotherapy, normal healthy cells. The use of conventional
radiation therapy, and hormonal therapy. cytotoxic agents is however limited clinically by
various adverse drug reactions reported by the
After the first promising results of cytotoxic patients. These adverse drug reactions are mainly as
treatment during the 1940s there was a tremendous a result of indiscriminate distribution and lethal
surge of activity to discover new anticancer agents effects of the cytotoxic agents on normal healthy
in the hope of finding the ideal drug that would cells. There is therefore the need for selective and
eradicate the tumour whilst having no harmful targeted drug delivery to the tumour cells thereby
effects on normal tissue. Decades later this hope is increasing concentration of the cytotoxic drug in the
yet to be fulfilled, but the search for new cytotoxic tumour areas relatively to other parts of the body
agent has yielded many thousands of compounds (Wu and Senter, 2005).
with possible therapeutic applications, (Stenvang et
al., 2013). Presently plethoras of chemotherapeutic One of the current most useful strategies is the use
cancer drugs exist for treatment of haematological of antibody as carrier (delivery vehicle) of cytotoxic
and other solid tumours. These drugs are divided agent. This strategy is particularly useful in
into six major classes which include: alkylating improving the selective delivery of cytotoxic drugs
agents, anti-metabolites, anti-tumour antibiotics, since the vehicle (antibodies) can reorganize and
topoisomerase inhibitors, corticosteroids and mitotic bind selectivity to tumour associated antigen thereby
inhibitors, (Jain, 1990; Dubowchik & Walker 1999). delivering the cytotoxic drugs to the tumour cells
through passive and active internalization,
(Waldmann, 2003). Conjugation of cytotoxic agent

with antibody has been reported to improve the drug conjugates (ADC) offer a sustained release of
pharmacokinetic profile, by decreasing the volume the attached drug from the carrier results in a
of distribution and prolonging the distribution and prolonged high intra-tumoural drug levels (Wu and
elimination phase of the attached cytotoxic agents Senter, 2005).
(Cheng and Xu, 2008). Additionally, Antibody –
Table 1: Some identified Tumour cells associated antigens

Types of Cancer Associated Surface Antigen
Non-Hodgkin Lymphoma CD20, CD22 and HLA-DR
Colorectal Cancer EGFR, A33 and Carcinoembryonic antigen (CEA)
Renal Carcinoma G250
Breast Cancer HER2
Small-cell lung cancer CD56
Solid Tumour Vascular endothelial growth factor (VEGF) and
VEGF2
Prostate Cancer Prostate-specific membrane antigen
Therapeutics Monoclonal antibodies cancers has revealed a broad array of targets that are
Uses of monoclononal antibodies as therapeutic over expressed, mutated or selectively expressed
agent for the treatment and management of various compared with normal tissues (Van den Eynde and
types of cancer has become established over the past Scott, 1989).
two decades and is now one of the most successful
and important strategies for treating patients with Monoclonal antibodies are immunoglobulins
haematological malignancies and solid tumours. The produced by single clone of cells (cells that are
fundamental basis for the use of monoclonal derived from to a single progenitor and genetically
antibodies as therapeutic agent dates back to the identical) and are identical to one another, in terms
original observations of antigen expression by of weight as well as chain structure. Therefore, they
tumour cells through serological techniques in the are highly antigen binding specific and offer more
1960s (Rettig and Old, 1989). The definition of cell consistent efficacy and predictable toxicity in vivo
surface antigens that are expressed by human (Delmonico and Cosimi, 1988).
Figure 3: Monoclonal antibodies

 F ab = Fragment antigen-binding domain

 Consist of variable (V) and constant (C) domains
 Antigen binding CDR domains found at this terminal
 Very useful for recognition and binding to antigen
 F c = Fragment crystallizable/constant domain
Ideal location for drug conjugation
Consist of a CH2 and CH3 domains
Figure 3: Four types of Monoclonal antibodies
The earliest monoclonal antibodies examined in been shown to have much shorter clearance rates
animal and clinical studies were murine antibodies. than human monoclonal antibodies. One approach to
Because of their non-human origin, they are overcome these problems has been to cleave the
immunogenic in humans (they have a tendency to antibody (e.g. by papain digestion) into its
elicit a human anti-murine antibody (HAMA) respective fragments, (FC and FAB), (Myers and
response). HAMA response is an immune response Ron, 1992).
generated against a mouse antibody. They also have
Figure 4: Schematic representation of papain digestion
In general, the FAB fragments are less immunogenic Among the feature unique to monoclonal antibodies
compared with corresponding intact antibodies and are their ability to be produced in unlimited
their smaller molecular size may facilitate quantities, their ability to bind to a specific antigen
penetration into tumour tissue resulting in a longer and their homogeneity.
systemic half-life (Larson et al., 1983). FAB Monoclonal antibodies abilities to; recognize, bind,
fragment uses is however limited, since they often attack, and eradicate specific antigens, is today
lose some of their antigen recognition and binding utilized in combating some tumour types with great
capacity and in some cases, the therapeutic effect clinical success, (Peter, 2011).
may depend on the FC portion of the antibody The development of first fully human therapeutic
(Kohler and Milstein, 1975). . antibody follows years of logical drug design
through application of recombinant DNA

technology which has made it possible to produced receptor blockade or agonist activity, induction of
fully human antibodies and humanized antibodies. apoptosis, or delivery of a drug or cytotoxic agent);
Both human and humanized monoclonal antibodies immune-mediated cell killing mechanisms
are today the template on which therapeutic (including, complement-dependent cytotoxicity
antibodies are built, (Reily et al., 1994; Winter and (CDC), antibody-dependent cellular cytotoxicity
Harris 1993). At present, there are various (ADCC) and regulation of T cell function); and
therapeutic monoclonal antibodies approved for the specific effects of an antibody on tumour
treatment and management of various types of vasculature and stroma. The FC portion of
cancer. The mechanism of their anti-tumour effect is monoclonal antibodies is particularly important for
thought to include complement dependent mediating tumour cell killing through CDC and
cytotoxicity, antibody-dependent cellular ADCC. All of these approaches have been
cytotoxicity and steric hindrance of the function of successfully applied therapeutically. For example
the target antigens, and a large number of additional Cetuximab and Trastuzumab mechanism is by
therapeutic antibodies are currently being tested in abrogation of tumour cell signalling; while
early stage and late-stage clinical trials (Reff et al., Rituximab is by the induction of effect or function
2002). primarily through ADCC; however Ipilimumab
works by immune modulation of T cell function.
The tumour killing ability of therapeutics antibodies These are the approaches that have been most
can be summarized as being due to several successful therapeutically, and that have led to the
mechanisms: direct action of the antibody (through approval of antibodies using these mechanisms.
Table 1: FDA approved therapeutic monoclonal antibodies, the target antigens and their clinical
indications.
Generic name Proprietary Antigen Year of Clinical indication
name approval
Rituximab Rituxin® CD20 1997 Non-Hodgkin’s lymphoma
Trastuzumab Herceptin® HER-2 1998 Metastatic Breast Cancer
Panitumumab VectibixTM EGFR1 2006 Merkel Cell Carcinoma
Ofatumumab ArzerraTM CD20 2009 Refractory Chronic Lymphocytic

Leukaemia
Ipilimumab YervoyTM CD152 2011 Multiple Myeloma
Pertuzumab PerjetaTM EGFR2, 2012 Breast Cancer

HER-2
Antibody-drug conjugates (ADC) limitations to the effective uses of therapeutic

A common theme in drug discovery and monoclonal antibodies include; biochemical barriers
development is to address limitations in current such as antibody receptor affinity and antigen. In
anticancer therapies by designing novel formulations addition to these problems, the therapeutic efficacy
of these well known cytotoxic drugs. Several can be limited due to the inability of antibodies to

marshal an immune response sufficient to cause and selectively bind to specific tumour associated
target cell death (Wu and Senter, 2005 and Ruiz- antigens, thereby reducing systemic toxicity and
Cabella et al., 2002). The emphasis is now on the increasing the cell-killing potential of monoclonal
use of monoclonal antibodies as delivery vehicles antibodies.
for toxic agents ( Herbertson, et al., 2009 and Wu
and Senter, 2009). Interestingly, ADC have been shown to have high
potency in haematological malignancies, and the list
Since, monoclonal antibodies are generally of approved ADC by the regulatory authorities is
generated against specific antigens, and as such growing daily, for example, Brentuximab Vedotin is
when conjugated to cytotoxic drugs, can selectively an ADC used in patients with CD30-positive
deliver drugs to cancer cells while minimizing Hodgkins (Hughes, 2010: Weiner, et al., 2010 and
damage to normal cells; and of all the carrier Youne et al., 2010). Most ADCs use either IgG or
systems available, monoclonal antibodies are IgG1 isotype antibody as the drug delivery vehicle
gaining more relevancies because of their high due to their favourable pharmacokinetic properties
specificity. Antibody-drug conjugates (ADC) as the when compared to other antibody types. Only a few
name implies, are covalently linked cytotoxic agent of the ADCs contain IgG2 or IgG4, as is AGS-
and monoclonal antibodies (mAbs) formulated to 16M8F (anti-ENPP3 IgG2-MMAF) and Inotuzumab
selectively deliver the cytotoxic agent to tumour Ozogamicin (anti-CD22 IgG4-calicheamicin)
cells utilizing the ability of the mAbs to recognized, respectively. (McDonagh et al., 2008).
Figure 3: Structural representation of ADC
The successful development of an ADC involves a of antigen expression using panels of normal and
complex process of scientific and preclinical malignant tissues; study of the immune effect and
evaluations, informed by deep understanding of functions, effect of antibodies on cell signalling
cancer biology and the properties of antibodies pathways; in vivo analysis of the antibodies
in vivo. Essential pre-clinical characterization localization and distribution in transplanted or
including identification of the physical and chemical syngeneic tumour systems; antibodies chimerization
properties of the antibody; detailed specific analysis and humanization (or the use of phage display and

xenomice to produce fully human antibodies); and Monomethyl Auristatin E (MMAE, Vedotin) is a
observation of the in-vivo therapeutic activities of very good potent MTI candidate that inhibits cell
the antibodies conjugated with cytotoxic agents or division by blocking the polymerisation of tubulin.
radioactive isotopes. For effective formulation of an MMAE is 100-1000 times more potent
ADC the target antigen must be carefully selected than Doxorubicin (Adriamycin/Rubex) and as such
since both the safety and therapeutic efficacy depend it must not be used alone but rather as an ADC
on effective binding of ADC to the target antigen. (Asundi et al., 2011; Younes et al., 2011; Junutula,
2008 and Francisco et al., 2003).
The ‘ideal’ target antigen must have a high-level
expression in cancer cells, little to no expression in 2. DNA-damaging agents
normal cells, exclusively expressed on the tumour The discovery of the alkylating-like platinum agents
cell surfaces, and there must be no shedding into the had a significant positive impact on anticancer drug
blood by cleavage of the antigen from cancer cell research. Cisplatin was discovered by accident in the
surfaces (Deckert, 2009 and Ellis and Hicklin, 1960s, when a magnetic field generated by platinum
2008). Optimal drug - antibodies ratio, (DAR) is electrodes was shown to block E. coli cell division
also critical in successful development of an ADC. (Rosenberg et al., 1965).
Attaching sub optimal amount of the drug molecules
will lead to decreased efficacy, likewise attaching DNA integrity is critical for proper cellular
too many may make the ADC to become unstable, function and proliferation. Tumour cells are capable
negatively alter the pharmacokinetic properties, of ignoring normal cell-cycle checkpoints, allowing
increased plasma clearance, reduced half-life and the cells to achieve high proliferation rates; this also
increased systemic toxicity. makes them more susceptible to DNA damage. The
concept of aiming at DNA as a target for anticancer
The nature and type of linker to be used, the reaction drugs inspired the development of numerous
temperature, as well as, cytotoxic drugs to be use in anticancer compounds, such as Cisplatin,
ADC formulation must contain a suitable functional Doxorubicin, 5-Fluorouracil, Etoposide, and
group for conjugation reactions and must be stable Gemcitabine (Fischhaber et al., 1999). All of these
under physiological conditions, (Sedlacek et al., drugs function by binding the minor groove of DNA
1992). Two classes of drugs used to construct, and causing DNA stand scission, alkylation, or
ADCs in cancer therapy are discussed below; cross-linking (Sievers and Linenberger, 2001). The
two most successful DNA- damaging agents are
1. Microtubule inhibitors (MIT) Cisplatin and Doxorubicin.
Microtubules are important cellular targets for
anticancer therapy because of their key role in Cisplatin, as its name implies, contains a platinum
mitosis. Microtubule inhibitors (MTI) such as core with two chloride leaving groups and two
Taxanes, Vinca Alkaloids, and Epothilones stabilize amine non-leaving groups. After internization of
(up regulation) or destabilize (down regulation) Cisplatin into the tumour cells, equation of the
microtubules, thereby suppressing microtubule chloride groups allows the platinum to bind guanine
dynamics required for proper mitotic function, residues and, to a lesser extent, adenine residues to
effectively blocking cell cycle progression and form adducts on DNA.
resulting in apoptosis. Pharmaceutical formulation
of MTIs as ADCs is a good strategy that ensures When more than one platinum adducts form on
maxima benefits are obtained from MITs by adjacent bases on the same DNA strand, they form
providing higher efficacy with limited systemic intra-strand cross-links (Siddik, 2003). Cisplatin
toxicity. This also helps overcome tumour resistance therapy can cure over 90% of all testicular cancer
to conventional MTIs (Perez, 2012). cases and also has good efficacy in the treatment of
ovarian, bladder, head and neck, and cervical
cancers; however, Cisplatin is extremely toxic to the

kidney and the nervous system thereby limiting its lymphomas, and acute lymphoblastic or
clinical uses (Kelland, 2007). myeloblastic leukemias. Doxorubicin and the newer
Series of efforts were made with little success, at Anthracyclines such as Epirubicin and Idarubicin
reducing the nephrotoxicity and neurotoxicity by have become mainstays of cancer chemotherapy
developing Cisplatin analogs. Recently Cisplatin (Minotti et al., 2004). All Anthracyclines are
was formulated and evaluated as an ADC however extremely cardio toxic, including
incorporating Cisplatin and monoclonal antibody. cardiomyopathy and congestive heart failure (CHF)
The problems of adverse drug reactions alight above as a result of their multiple mechanisms of action,
were completely solved and Cisplatin ADC is of (Olson and Mushlin 1990).
great clinical success today (Baruah et al., 2004).
Trastuzumab-doxorubicin conjugate (T-Dox) an
In a similar fit, Doxorubicin an Anthracycline ADC was shown to selectively target HER2-
antibiotic with Antineoplastics activities via the expressing cells and reduced the adverse drug
poisoning of topoisomerase II, and intercalate into reaction experience with the use of doxorubicin in
DNA, generate free radicals, bind and alkylate low HER2 expressing human cardiomyocytes. Since
DNA, crosslink DNA, interfere with helicase Doxorubicin is an established chemotherapeutic
activity, and induce apoptosis (Cutts et al., 2005). agent, T-Dox provides unique value for cancer
Doxorubicin is derived from Streptomyces peucetius patients with high HER2 expression, who showed
and it is widely used to treat breast cancer, small- benefit from Doxorubicin (Nigyan et al., 2013).
cell lung tumours, soft tissue sarcomas and
Figure 4: Three basic composition of an ADC

ADC Antigen Antibody isotype Cytotoxic agent Indications

Target used
Pinatuzumab vedotin CD22 Hz IgG1 MMAE NHL/DLBCL
(DCDT2980S, RG7593)
Inotuzumab ozogamicin CD22 Hz IgG4 Calicheamicin ALL
(CMC-544)
Trastuzumab emtansine HER2 Hz IgG1 DM1 HER2+breast
(Kadcyla®, T-DM1 cancer
BT-062 CD138 Hz IgG1 DM4 Multiple myeloma
Glembatumomab GPNMB Hu IgG2 MMAE Breast
vedotin (CDX-011) cancer/Melanoma
SYD985 HER2 Hz Duocarmycin Breast cancer
Lorvotuzumab CD56 Hz IgG1 DM1 SCLC
mertansine (IMGN-901,
huN901-DM1)
Keys: Hu: Human, Hz: Humanized, HL: Hodgkin’s Lymphoma, ALL: Acute Lymphoblastic Leukaemia, SCLC:
Small-Cell Lung Cancer, NHL: Non-Hodgkin’s Lymphoma and DLBCL: Diffuse Large B Cell Lymphoma.
Linkers lysosomal acid, lysosomal enzymes or intracellular

Pharmaceutical development and formulation of glutathione ((Ducry and Stump, 2010). Based on
ADC requires an in-depth understanding of target their mechanism of cleavage, cleavable linkers are
tumour associated antigen, conjugate internalization further sub-classified into acid-labile linkers,
process, drug potency and most importantly stability Protease-cleavable linkers and disulfide linkers with
of the linker attaching the cytotoxic drug to the their respective examples as hydrazone, valine-
antibody. Additionally, understanding the citruline and SPP (N-succinimidyl-4-(2-
conjugation methods, drug-to-antibody ratio (DAR), pyridyldithio) pentanoate). However, in non-
the effects of drug conjugation on antibody cleavable linkers the release of the cytotoxic agent
properties and type of linker are critical in dependent on internalization of the ADC and
formulation development of safe and effective degradation of the ADC solely by lysosomal enzyme
ADCs, (Ravandi, 2011). The biggest challenge in (Carter and Senter 2008).
the development of antibody-drug conjugates is the
selection of suitable linkers that will offer high drug- There are several conjugation techniques of which
linker stability in systemic circulation, thereby the most current and frequently used involves
preventing dose duping of the cytotoxic agent limited reduction of intra or inter-chain disulfide
(Carter and Senter, 2008). An ideal linker should be bonds by the addition of reducing agents into the
stable in systemic circulation, and must allow rapid buffer containing the antibody. Limited reduction of
release of attached drug within the tumour cells. the intact antibody results in the formation of free
Linkers can be broadly categorized into Cleavable thiols without changing the structural characteristics
and Non-cleavable. of the antibody and antigen binding domain. With its
structure and typical binding domain preserved the
While cleavable linkers are stable in systemic antibody will retain its ability to discriminate
circulation, but they, rapidly release the attached between healthy and tumour cells. Other conjugation
drug within the tumour cells upon cleavage by methods are as in table 3.

Table 3: Different conjugations/Linker reactions used in constructing ADCs

Linker Drug Release Mechanism
Disulfide Linkage Designed to cleave the bond between antibody and
the cytotoxic drug by disulfide exchange with
intracellular thiol such as glutathione.
Thioesther The drug is release by intracellular proteolytic
degradation of the ADC
Hydrazone Hydrazone linkage is systemically stable, the
cytotoxic drug is release by acid degradation within
the tumour cells cytoplasm
Peptide The drug is released from the ADC by enzymatic
hydrolysis by the lysosomal proteases e.g cathepsin
Chemically labile linkers, such Mechanisms of action of ADC

as hydrazones and disulfides, may offer limited After administration of an ADC, the monoclonal
plasma stability. Peptide-based linker technologies antibody component of the ADC directs the
may offer better controlled drug-linker stability and transportation of ADC to the cancer cells and binds
drug release. Peptidic bonds are also expected to to the target antigen on the surface of the cancer
have good serum stability. Cleavable dipeptide cells to produce antibody-drug conjugate-antigen
linkers like Val-Ala and Val-Cit rely on processes complex (stage 1). The second stage involves the
inside the cell to liberate the payload, as they internalization of the antibody-drug conjugate-
undergo rapid hydrolysis in the presence antigen complex into the tumour cell. Consequently,
of lysosomal extracts (Sanderson et al., 2005). The the antibody-drug conjugate -antigen complex fuses
selection of the linker depends on the tumour with tumour cells endosome, to initiate the release of
associated antigen targeted, therefore pre- the antigen from the antibody-drug conjugate. At
formulation studies is critical to determine the this stage, the antigen may be recycled back to the
optimal combination of the correct linker, the target cell membrane. This process is crucial for eventual
antigen and optimum drug-antibody ratio (ADR) activity of the cytotoxic drug (Chames et al., 2009).
(Younes et al., 2012).
Figure5: mechanism of Action of ADC

The third stage involves internalization of the ADC Carter, P.J. and Senter, P.D. (2008). Antibody-drug
which is transported through the late endosome conjugates for cancer therapy. Cancer Journal;
pathway to the intracellular compartment of a 3:154-169.
lysosome, where it is degraded to release the Chabner, B. A. and Roberts, T.G. (2005). Timeline:
cytotoxic drug. It is important that the ADC must Chemotherapy and the war on cancer. Nature
release the attached cytotoxic drugs after Reviews Cancer; 5: 65–72
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intracellular pH, reduction potential or enzyme (2009). Therapeutic antibodies: the future.
concentration to trigger the release of the cytotoxic British Journal of Pharmacology; 157: 220–
in the cell. The cytotoxic drug thereafter enters the 233.
cytoplasm, where it binds to its molecular target. Chari, R.V.J. (2008). Targeted cancer therapy:
The interaction of the cytotoxic drug with DNA and Conferring specificity to cytotoxic drugs.
microtubules initiates a chain of events leading to Accounts Chemical Research; 41: 98–107.
apoptosis (Chames et al., 2009). Cheng, Y. and Xu, T. (2008). The effect of
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It will not be out of context to refer to these ADCs covalently attached drugs. European Journal of
as smart bomb against various types of cancer. Their Medicinal Chemistry; 43: 2291–2297.
ability to recognize tumour associated antigens and Co, M.S. and Queen, C. (1991). Humanized
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some unlimited possibilities, and its use has Phillips, D.R. (2005). The power and potential
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of ADCs. Doronina, S.O., Toki, B.E., Torgov, M.Y., et al.
(2003). Development of potent monoclonal
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Original Research
SJMLS-1(2)-2016-017
Cystatin C- A Novel Biomarker for Early Detection of Renal
Impairment in Patient With HIV/AIDS
Ikpeama E A 1, Ikpeama OJ* 2, Okafor PA 3, Ikpeama, C.A. 4, Ikpeama, C.J.5, Ogwuegbu, J.U. 6
Department of Anatomy, Anambra State University, Uli 1, Integrated Health Program Dioceses of Makurdi,
Benue State 2, School of Medical Laboratory Science, Ahmadu Bello University Teaching Hospital Zaria 3,
Federal Medical Centre Birinin Kebbi 4, Médecins Sans Frontières 5, Department of Medicine Imo State
University Owerri 6.
Corresponding Author*: ikpeama35@gmail.com/+234-806-261-9025
Abstract There is need for inclusion of a sensitive (Cystatin

Human immunodeficiency virus (HIV) - related C) renal marker as a routine check in these patients.
kidney disease is one of the leading causes of death This will help in early detection of renal diseases,
worldwide most especially in Nigeria. To access the thereby preventing end stage renal disease.
possibility of detecting a more sensitive biomarker
for the early detection of renal disease in HIV/AIDS Keywords: Cystatin C, Biomarker, Renal
patients., serum creatinine, Cystatin C, Urea, Impairment, HIV/AIDS
proteinuria and microalbuminuria were evaluated in
two hundred newly diagnosed HIV seropositive Introduction
patients, two hundred HIV/AIDS on therapy The first report of AIDS-related renal failure, which
(CD4>250), two hundred HIV/AIDS on therapy we now recognize as HIV-associated nephropathy
(CD4<250) and one hundred and fifty apparently
(HIVAN), was published in the mid-1980s (Nicastri
healthy HIV seronegative individuals as control.
Results showed creatinine value of 0.9±0.0mg/dl, et al., 1984). Before effective anti-retroviral therapy
1.3±0.4mg/dl, 1.2±0.2mg/dl and 1.3±0.0mg/dl in became available, HIVAN was so frequent, and its
controls, HIV patients with CD4 ≤250, HIV patients clinical features were so dramatic; beginning with
with CD4 ≥250 and newly diagnosed HIV patients heavy proteinuria, with rapid progression to end-
respectively. There was statistically significant stage renal disease (ESRD). In immune-suppressed
difference in the mean creatinine values among the patients, HIVAN became almost synonymous with
groups (p>0.05). Results shows urea value of HIV-associated chronic kidney disease (CKD). As
23±0.3mg/dl, 29±0.3mg/dl, 27±0.1mg/dl and HIV infection spread, the ESRD incidence increased
33±0.4mg/dl in controls, HIV patients with CD4 ≤250 substantially, and by the early 1990s, HIVAN
cell, HIV patients with CD4 ≥250 cell and newly
became the third leading cause of ESRD in HIV
diagnosed HIV patients respectively. There were
statistically significant differences in the mean urea patients aged 20–64 years (Klotman et al.,1996).
values among the groups (p>0.05). Results shows
Cystanin C value of 0.7±0.02mg/l, 1.5±0.1mg/l, Kidney disease tends to be asymptomatic and is
1.1±0.2mg/l and 1.1±0.3mg/l in controls, HIV usually not the primary focus of a visit to an HIV
patients with CD4 ≤250 cell, HIV patients with CD4 clinic (Gupta et al., 2005). The presence of kidney
≥250 cell and newly diagnosed HIV patients disease should be anticipated; screening and proper
respectively. There was a statistically significant interpretation of the relationship between serum
difference in the mean Cystanin C values among the creatinine level and GFR are recommended. Just as
subjects and controls (p>0.05). There was optimal control of HIV replication is achievable for
significant difference in the mean urine protein value
most patients, so too is control of hypertension and
of HIV patients when compared with control, there
were no statistically significant difference in the diabetes. The future holds enormous opportunities
mean value of microalbuminuria in HIV patients for research in new markers for early detection of
when compared to control. Renal disease is kidney disease, prevention strategies, novel
frequent in patients having HIV/AIDS infection. therapeutics, and a better understanding of the

interaction between the Black race and kidney patients with low GFR and therefore can yield
disease. Until that time, the incidence and spectrum variable results in persons with normal renal
of kidney diseases in HIV-infected patients have function (Stevens et al., 2007). Nonetheless, these
been altered by the widespread use of highly active estimates remain the most highly validated formulas
antiretroviral therapy (HAART). The clinical cause available, and both equations are more sensitive than
of kidney disease is more indolent, the risk of ESRD measurement of serum creatinine alone.
has been reduced by 40%–60%, the 1-year survival
rate while undergoing dialysis has increased from Statement of the Problem
25% to 75%, and kidney transplantation is a viable HIV/AIDS patients are on the increase all over the
option (USRDS. 2007). Despite these globe most importantly in Nigeria. The use of
improvements, risk factors for kidney disease are HAART in our entire medical centers for the
highly prevalent among HIV-infected patients, and management of this group of patients has
kidney disease remains a significant cause of tremendously improved the well-being of this group
morbidity and mortality, even among those patients of patients. Early detection of renal complication
receiving Highly Active Anti-Retroviral Therapy associated with HIV/AIDS could help reduce their
(HAART). morbidity and mortality rate, hence there is need for
the identification of a more sensitive biomarker for
The kidneys are known reservoirs for persistent HIV early detection of renal disease.
replication, even when the peripheral viral load is
suppressed with HAART (Winston et al., 2001). Justification
The kidneys of patients with HIV-associated (a)The level of serum creatinine, urea and cystatin C
nephropathy have a dense tubulointerstitial in HIV/AIDS is not known in our environment.
inflammatory infiltrate that is primarily composed of (b)The status of urine microalbuminuria and
activated CD4+ and CD8+ cells, and the amount of proteinuria in HIV/AIDS is not known in our
the infiltrate appears to correlate with the degree of environment.
clinical nephropathy (Kimmel et al., 2003). It has (c ) There is need for the use of a more sensitive
been suggested that HIV-infected renal tubular biochemical marker for accessing renal function in
epithelial cells trigger up-regulation of patients with HIV/AIDS.
proinflammatory genes (Ross et al., 2006). This (d) The prevalence of HIV/AIDS- related renal
proinflammatory renal environment may stimulate disease is not known in our environment
increased immune activation in the kidneys, which
consequently may lead to heightened systemic Aim
immune activation. Alternatively, patients with The aim of this present study was to access the
increased systemic immune activation may be prone possibility of detecting a more sensitive biomarker
to infiltration of activated T cells into the kidneys, for the early detection of renal disease in HIV/AIDS
thereby leading to proteinuria and reduced renal patients.
function. Chronic renal disease (CKD) is defined as
kidney damage or reduced kidney function that Objectives of the Study
persists for >3 months (Coresh et al., 2003). A To evaluate the serum creatinine, urea and cystatin
useful indicator of kidney damage is elevated C level in newly diagnosed HIV patient, those on
urinary protein excretion, measured qualitatively therapy and the control group.
with use of a urine dipstick or measured
quantitatively with use of a spot urine protein to To evaluate the microalbuminuria and urine protein
creatinine ratio (or 24-h urine collection). Kidney (proteinuria) in newly diagnosed, those on therapy
function can be reliably estimated from the serum and the control group.
creatinine by calculating the creatinine clearance or To compare our findings with those reported in
glomerular filtration rate (GFR) through use of the other part of the world.
Cockcroft-Gault equation or Modification of Diet in
Renal Disease (MDRD) equations, respectively. A Materials and Methods
GFR <60 mL/min meets criteria for CKD, a cutoff Description of Study Area
supported by epidemiologic data linking lower GFR Seven hundred and fifty patients attending medical
to an increased frequency of hospitalization, treatment in St Thomas Hospital Ihugh. Ihugh is
cardiovascular events, or death. MDRD equations situated in Vandeiky Local Government Area of
has been specifically validated in the HIV-infected Benue located between latitude 70ºN by Gboko and
population. The MDRD equation was derived from Buruku Local Governments Areas, in the South

by Vandeikya Local Government, in the East by (iii) All adult HIV seropositive, without of any
Kwande and in the West by Konshisha Local underlying disease like diabetes, hypertension
Government Area. In Nigeria, its geographical
coordinates are 7° 1' 0" North, 9° 2' 0" East and its Exclusion Criteria
original name (with diacritics) is Ihugh. The study (i) All adult HIV seropositive patients who did
included two hundred newly diagnosed HIV not offer a verbal informed consent to be
seropositive patients, two hundred HIV/AIDS on enrolled into the study.
therapy (CD4≥250), two hundred HIV/AIDS on (ii) All adult HIV seropositive patients with sign
therapy (CD4≤250) and one hundred and fifty and symptom of renal disease.
apparently healthy HIV seronegative individuals as (iii) All adult HIV seropositive patients with
control. underlying disease like diabetes,
hypertension.
Ethical Consideration
Approval for the study was obtained from St Collection of Samples
Thomas Hospital Ihugh Medical Advisory Ten (10) ml of blood samples were collected in plain
Committee. Verbal informed consent of the patients bottle. This was allowed to clot within 30 minutes of
was also obtained. Patient’s anonymity was collection. The samples were then centrifuged at
maintained; the data generated was treated with 3000 rpm for 5 minutes to obtain neat serum
strict confidentiality and was used for the purpose of samples, which were harvested into Bijou bottles
this research only. and labeled accordingly. The serum samples were
stored at 4oc until assayed. EDTA tube was used to
Sample Size collect samples for the estimation of CD4 count
The sample size was calculated using the formula among the participants.
n = pq Analytical Methods
[E/1.96]2 CD4 was carried out using the Partec Flow
(WHO, 1989) Cytometer with an excitation light source of 488nm
Where, or 532nm (blue or green solid state laser). The
n = sample size Cyflow counter is set for counting CD4+T –cell per
p = Prevalence of previous studies in Kaduna µl whole cell as displayed automatically by the
state = 4.7 (Sentinel survey 2006) instrument software which is controlled by an
q = 100 – p operator (Fryland et al., 2004). Serum creatinine
was estimated using the method (Jaffe, 1886).
= 100 – 4.7 Diacethylmonoxine method was used for Urea assay
(Bruinsma et al., 2014). Protein and Microalbumin
= 95.3 assay was carried out using the H11-MA urinalysis
E = allowable error = 5% reagent strips. Cystatin C assay was carried out
using the Diazyme’s Cystatin C assay based on a
N = 4.7 x 95.3 latex enhanced immuno-turbidimetric assay
[5/1.96]2 (Erlandsen et al., 1999).
= 447.91 Statistical Analysis

6.51 Data collected were entered into IBM compatible
microcomputer. Data analysis was done using
= 69 + 7 (10% for attrition) Statistical Package for Social Science (SPSS)
software package. Correlation was by Pearson’s
= 76 approximately 80 patients. Correlation Coefficient. The Mean and Standard
Error of Mean (SEM) were computed and results
Inclusion Criteria were expressed as mean + SEM. Student t-test was
(i) All adult HIV seropositive patients, who used to compare differences between means.
consented to being included as participants in
the study were enrolled into the study. Result
(ii) All adult HIV seropositive patients, without The results obtained in the present study are
any sign and symptom of renal disease. expressed as mean ± standard error of mean (mean
±SEM) and are presented in tables 4.1 to 4.9.

HIV patients and controls. There were significant

Table 1 shows the mean values of urea, creatinine increases in the mean values of age, weight, BMI
and Cystacin C in HIV patients with CD4 ≤ 250 recorded in newly diagnosed HIV patients compared
cells/ml and control groups. There were significant with control groups (p< 0.05). There were
increases in the mean values of urea, Creatinine, significant differences in the mean values of height,
Cystatin C recorded in HIV patients compared with recorded in newly diagnosed HIV patients
controls (p<0.05). Compared with controls (p> 0.05).
Table 7 shows the mean±SEM values of proteinuria
Table 2 shows the mean values of urea, creatinine and microalbuminuria in newly diagnosed HIV
and Cystatin C in HIV Patients with CD4 ≥ 250 and patients and controls. There was a significant
controls. There were significant increases in the increase in the mean value of proteinuria recorded in
mean values of urea and Cystatin C recorded in HIV newly diagnosed HIV patients compared with
Patients with CD4 ≥ 250cells/ml compared with control groups (p< 0.05) and there was no
control groups (p< 0.05). There was no significant significant increase in the mean value of
difference in the mean value of creatinine, recorded microalbuminuria recorded in newly diagnosed HIV
in HIV patients compared with controls (p> 0.05). patients compared with control group.
Table 3 shows the mean values of urea, creatinine Table 8 shows the mean±SEM values of proteinuria
and Cystatin C in newly diagnosed HIV patients and and microalbuminuria HIV patients with CD4 ≥ 250
controls. There were significant increases in the and controls. There was no significant difference
mean values of urea, creatinine and Cystatin C between proteinuria and microalbuminuria HIV
recorded in HIV patients compared with controls patients with CD4 ≥ 250 compared with controls (p>
(p<0.05). 0.05).
Table 4 shows the mean±SEM values of Age (yrs), Table 9 shows the mean values of protein and
Height (m), weight (kg), BMI of HIV patients (CD4 microalbuminuria between HIV patients with CD4
≤ 250) and Controls. There were significant ≤250 and control group. There were significant
increases in the mean values of age, weight and BMI increases in proteinuria in HIV patients with CD4
recorded in HIV patients (CD4 ≤ 250) compared ≤250 cell compared with control (p< 0.05) and there
with controls (p<0.05) and there was no significant was no significant increase in the mean value of
increase in the mean value of height of HIV patients microalbuminuria recorded in HIV patients with
(CD4 ≤ 250) recorded compared with control group. CD4 ≤250 cell compared with control group.
Table 5 shows the mean±SEM of Ages (yrs), Figure 1 shows strong correlation between plasma
Height(m), weight(kg), BMI of HIV patients (CD4 ≥ cystatin C to Serum Creatinine. Linear regression:
250) and Controls. There were significant increases CysC = 0.201SCR+ 0.512; r = 0.976; Syux = 0.622;
in the mean values of age, weight and BMI recorded n=150.
in HIV patients (CD4≥ 250) compared with controls
(p<0.05). Figure 2 shows strong correlation between plasma
cystatin C to Serum Creatinine. Linear regression:
Table 6 shows the mean±SEM value of Ages (yrs), CysC = 0.104SCr+ 0.514; r = 0.513; Syux = 0.322;
Height (m), weight(kg) and BMI in newly diagnosed n=150.
Table 1: Mean values of urea, creatinine and Cystatin C in HIV patients with CD4≤ 250 cells/ml and
control groups.
Groups N Urea (mg/dl) Creatinine (mg/dl) Cystatin C (mg/l)
HIV patients (CD4 ≤ 250) 200 29±0.3 1.3 ±0.4 1.5±0.1
Controls 150 23±0.3 0.9±0.00 0.7±0.02

P-value 0.000 0.000 0.000

Table 2 –Mean values of Urea, Creatinine and Cystatin C in HIV Patients with CD4≥ 250 and controls.
Groups N Urea (mg/dl) Creatinine (mg/dl) Cystatin C (mg/l)
HIV patients (CD4 ≥ 250) 200 27±0.1 1.0±0.2 1.1±0.2

Controls 150 23±0.3 0.9±0.0 0.7±0.02
P-value 0.6 0 0.03 0.500
Table 3: Mean values of Urea, Creatinine and Cystatin C in newly diagnosed HIV patients and controls.
Group N Urea (mg/dl) Creatinine (mg/dl) Cystatin C (mg/l)
HIV patients (newly diagnosed) 200 33±0.4 1.3±0.0 1.1±0.3

Controls 150 23±0.3 0.9±0.0 0.7±0.02
P- value 0.000 0.610 0.500
Table 4: Mean ± SEM values of Age (Yrs), Height (m), weight (kg), BMI of HIV patients (CD4 ≤ 250)
and Controls.
Group N Age (Yrs) Height(m) Weight (kg) BMI
HIV patients (CD4 ≤ 250) 200 27±0.6 1.5±0.1 57±0.9 25.3±0.2

Controls 150 25±0.7 1.6±0.1 55±0.1 21.5±0.8
P-value 0.000 0.00 0.000 0.000
Table 5: Mean ± SEM of Ages (Yrs), Height(m), Weight(kg), BMI of HIV patients (CD4 ≥ 250) and
Controls.
Group N Ages (Yrs) Height(m) Weight(kg) BMI
HIV patients (CD4 ≥ 250) 200 31±0.5 1.6±0.2 65±0.5 25.3±0.7

Controls 150 25±0.7 1.6±0.1 55±0.1 21.5±0.8
P- value 0.000 0.210 0.000 0.000
Table 6: Mean ± SEM value of Ages (yrs), Height(m), weight(kg) and BMI in newly diagnosed HIV
patients and controls.
Groups N Ages (Yrs) Height(m) weight(kg) BMI
HIV patients (newly diagnosed) 200 39±0.7 1.5±0.4 58±0.8 25.7±0.5

Controls 150 25±0.7 1.6±0.1 55±0.1 21.5±0.8
P-Value 0.00 0.01 0.92 0.000

Table 7: Mean ± SEM values of proteinuria and microalbuminuria in newly diagnosed HIV patients
and controls.
Groups N Proteinuria (g/l) Microalbunuria (g/l)
Control group 150 0.03 ± 0.00 0.00 ± 0.00
Newly infected HIV 200 0.38 ± 0.10 0.07 ± 0.01
P-value 0.00 0.00
Table 8: Mean ± SEM values of Proteinuria and Microalbuminuria HIV patients with CD4 ≥ 250 and
controls
Group N Proteinuria(g/l) Microalbuminuria (g/l)
HIV patient CD4 ≥ 250 200 0.03 ± 0.00 0.00 ± 0.00
Control group 150 0.03 ± 0.00 0.00 ± 0.00
P-value 0.000 0.000
Table 9: Mean values of Proteinuria and Microalbuminuria between HIV patient with CD4 ≤250 and
Control group.
Group N Proteinuria(g/l) Microalbuminuria(g/l)
HIV patient with CD4≤ 250 200 0.16 ± 0.03 0.02 ± 0.00
Control group 150 0.03 ± 0.00 0.00 ± 0.00
P-value 0.000 0.000

Figure 1. Relation of Plasma Cystatin C to Serum Creatinine.

Linear regression: CysC = 0.201SCR+ 0.512; r = 0.976; Syux = 0.622; n=150.
Figure 2: Relation of Plasma Cystatin C to Serum Urea

Linear regression: CysC = 0.104SCr+ 0.514; r = 0.513; Syux = 0.322; n=150.

Discussion, Conclusion and Recommendation. 250cells/ml compared with control groups (p< 0.05).
Discussion There were no significant differences in the mean
HIV associated nephropathy, the most common values of creatinine recorded in HIV patients
renal disease in HIV patients was first described in compared with values in controls (p> 0.05). HIV
1984 (Rao et al., 1996 and Pardo et al., 1998). Most patients with (CD4 ≥ 250) had increased urea,
patients present with nephrotic syndrome, Cystatin C when compared with controls. This
progressive loss of renal function and without finding correlate with previous report (Jerzy et al.,
treatment progress to end stage renal dysfunction 2006) which indicated that HIV patients had a
(ESRD) within weeks to months (Langs et al., significant increase in serum Cystatin C
1990). Although HIV associated nephropathy is concentration compared with apparently healthy
usually diagnosed late in the course of HIV individuals. There were no significant differences in
infection, renal involvement can occur earlier, even urea and creatinine in both groups. Our finding is
during the acute retroviral syndrome prior to HIV consistent with a previous report (Kamga, et al.,
antibody seroconversion. 2011) in Nylon District Hospital, Douala, Cameroon
involving subjects 18 to 60 years which indicated
There were significant increases in the mean values that there was no significant difference in the urea,
of age, weight and BMI recorded in HIV patients creatinine, proteinuria in HIV positives and control
(CD4 ≤ 250) compared with values in controls groups. There was no significant difference between
(p<0.05). There were significant increases in the proteinuria and microalbuminuria between control
mean values of Urea, Creatinine, Cystacin C and HIV patients with CD4 ≥ 250 (p> 0.05).
recorded in HIV patients compared with values
obtained in controls (p<0.05). This finding There were significant increases in the mean values
correlates with the works of Moses and Colleagues of Urea, Creatinine and Cystatin C recorded in HIV
(2012). They reported that the mean serum Cystatin patients compared with values in controls (p<0.05).
C levels was significantly higher in the HIV-infected Our finding is consistent with previous report (Kara
patients when compared with the value in controls et al., 2007) which observed renal disease (renal
(p <0.05). Direct effects of HIV appear to play a insufficiency (CrCl <60 ml/min) identified in 11.5%
major role in the development of HIV- associated and CrCl <50 ml/min in 4.8% of antiretroviral-naive
nephropathy, and are characterized histologically by HIV-infected outpatient population in Western
collapsing glomerulosclerosis, thrombotic Kenya. Despite high correlation coefficients
microangiopathy and various forms of immune between the three-renal function parameters, the
complex glomerulonephritis. Hepatitis B and C co- estimating equations used, when compared to
infection, often co-pathogens with HIV, may affect creatinine clearance as calculated by Cockcroft–
kidneys similarly (Agari et al., 1989). There was Gault indicated a lower rate of moderate to severe
significant increase in protein and microalbumin in renal insufficiency identified by the Modification of
HIV patients with CD4 ≤250 cell when compared to Diet in Renal Disease equations. Proteinuria,
values in controls (p< 0.05). Previous reports defined as a urine dipstick protein of equal to or
(Emejulu et al., 2011 and Kamga et al., (2011) greater than 1+, was detected in only 23 subjects
indicated that serum urea concentrations were (6.2%). Renal insufficiency is not uncommon, even
significantly increased (p<0.05) in both male and in stable patients without diabetes or hypertension.
female patients compared to the controls. Although Conversely, proteinuria was unexpectedly infrequent
no significant difference was obtained in the serum in the population. In another report by Doutora et
creatinine levels of the patients to the control, al. (2011) that investigated the strategies for early
correlation analysis however revealed a positive detection of renal injury in HIV-infected patients
association between creatinine and urea levels in indicated that 17 patients had elevated levels of
both male (r=0.63) and female (r=0.68) HIV Cystatin C but with an estimated creatinine
patients. This finding is in consonance to this study clearance within normal range, 11 were on
since there were no significant increases in the mean antiretroviral therapy with tenofovir and/or
values of urea and creatinine recorded in HIV atazanavir. Fourteen patients were smokers and 10
patients compared with values obtained in controls patients had hepatitis C virus co-infection, which are
(p>0.05). known causes of inflammation. In a matched control
group of 27 patients (subject) Cystatin C levels was
There was a significant increase in the mean value within normal range, the majority of patients
of urea recorded in HIV patients with CD4 ≥ (subject) also were on an antiretroviral regimen of

tenofovir and/or atazanavir. However, none of them participants receiving or not receiving antiretroviral
had hepatitis C virus co-infection. Moreover, a therapy, compared with patients in two large
statistical association was found between high levels population-based studies.”All of this would tend to
of Cystatin C and alanine transaminase. Differences support the fact that HIV causes kidney disorders
between biomarkers’ levels and patients on and this increase the risk of poor outcomes in people
combinations with tenofovir, ritonavir boosted living with HIV. However, a previous report (Post et
atazanavir or both were also studied. Although there al., 2010) quite correctly point out that “although
was no statistically significant difference in changes in virologic control could plausibly
creatinine and estimated creatinine clearance, with influence kidney function, it is also possible that
Cystatin C, patients that were on atazanavir or changes in Cystatin C reflect the influence of viral
tenofovir, had a higher level of Cystatin C, replication on systemic inflammation”.
compared with patients that never were on these
drugs. For instance, in a US study looking at body In the present study, Cystatin C showed higher
fat and metabolic changes in HIV-positive patients increment above control than serum creatinine in
(the FRAM – Fat Redistribution and Metabolic early stages of kidney affection in HIV/AIDS-
Change in HIV Infection – cohort), investigators related nephropathy. A mild degree of renal
conducted a cross sectional sub-study where they dysfunction may develop unnoticed as creatinine
compared kidney function, as measured by Cystatin level may remain in the normal range despite a
C and creatinine levels in 1,008 HIV-positive major decline in GFR, and the use of serum
subjects and 208 HIV-negative controls (Odden et creatinine may inaccurately estimate GFR due to
al., 2007). Cystatin C measurements were dietary intake, tubular secretion of creatinine
consistently higher in the HIV-positive participants (Kyhse-Andersen et al., 1994). These results
(at levels that would be indicative of poor outcomes confirm those noticed by Coll et al. (2000). They
in the general population) but creatinine-based reported that serum cystatin C levels started to
eGFR levels were similar in HIV-infected increase when GFR was 88 ml/min/1.73 m2, while
individuals and controls. In a subsequent analysis of serum creatinine level begin to increase when GFR
the FRAM cohort, levels of Cystatin C were was 75ml/min 1.73 m2. These data indicate that
elevated in HIV-positive patients compared to the serum cystatin C may detect mild reduction in GFR
HIV-negative controls (mean level, 0.92mg/l vs. than serum creatinine. On the other hand, Shemesh
0.76mg/l, p < 0.001). But creatinine levels were et al. (1985) reported that serum creatinine is of
similar in the two groups of patients (0.87mg/dl vs. little value in estimating GFR, while increased
0.85mg/dl) (Odden et al., 2007). Cystatin C level serum creatinine with decreased GFR has been
was elevated in HIV-infected individuals compared reported in patients with several types of renal
to controls (p<0.001). In contrast, both mean failure (Bauer,1982). Newman and Price (1999)
creatinine levels and estimated glomerular filtration have suggested that Cystatin C is the best
rates appeared similar in HIV-infected individuals endogenous GFR marker.
and controls (p=.35) and (p=.06) respectively.
Persons with HIV infection were more likely to have There was a significant increase in the mean value
a cystatin C level greater than 1.0 mg/L (p<.001), a of age, weight, BMI recorded in newly diagnosed
threshold demonstrated to be associated with HIV Patients compared with control groups (p<
increased risk for death and cardiovascular and 0.05). It should also be noted that creatinine
kidney disease. production is closely related to muscle mass. Muscle
mass and GFR are dependent on age, both tending to
Another study using data from participants from the fall with increasing age, although it is important to
strategies for management of antiretroviral therapy note that BMI (height/ body mass) does influence
(SMART) study found that Cystatin C and other the function of the kidney especially if BMI is ≥25 a
biomarkers of serious health problems were elevated predisposing risk factors of hypertension which
in people living with HIV as compared to the affect the kidney directly hence increase in the
general population (based on data from two large Cystatin C, Urea, and creatinine. Although there was
studies monitoring the development of renal and a statistically significant difference among HIV
heart disease), even while people were taking infected subject (CD≥250 cell/l and CD≤250 cell/l)
antiretroviral therapy (Neuhaus et al., 2010). In when compared to control. There were no
summary, the investigators said, “we found that significant differences in the mean value of height,
markers of inflammation, coagulation, and renal recorded in newly diagnosed HIV patients compared
function were elevated in HIV-infected study with controls (p> 0.05).

(1985) first reported the correlation (r = 0.75– 0.77)

There was a significant increase in the mean value of Cys C concentrations with GFR measured by Cr-
of proteinuria recorded in newly diagnosed HIV EDTA clearance, and also found a similar
patients compared with values in control groups (p< correlation (r = 0.73– 0.75) for SCr vs Cr-EDTA
0.05). There was no significant increase of clearance in renal patients ranging in age from 7 to
microalbuminuria in the subjects. There was no 77 years. Stronger correlation to Cr-EDTA clearance
significant difference between protein and (r = 0.87) together with a greater distinction from
microalbumin among HIV patients with CD4 ≥ 250 the plasma SCr correlation (r = 0.71) were reported
compared with controls (p> 0.05). There were in a more recent study using a particle enhanced
significant increases in proteinuria in HIV patients turbidimetric assay for Cys C measurement in
with CD4 ≤250 compared with control (p< 0.05). patients 8–81 years of age (Nilsson-Ehle et al.,
There was no significant increase of 1994). Similar numbers for the correlation of Cys C
microalbuminuria in the subjects. vs Cr-EDTA clearance (r 5 0.81) were reported in
the most recent studies (Newman, 1995), but the
Historically, microalbuminuria has been assumed to correlation using SCR was markedly lower (r
result from alterations in glomerular filtration =0.50). According to Stickle et al. (1998) in a study
secondary to changes in intraglomerular pressure of pediatric patients there was high correlation
and/or structural changes of the podocyte or between Cys C vs Creatinine clearance (r = 0.77 for
glomerular basement membrane. Recent evidence in 4–12 years; and r = 0.87 for 12–19 years) is
rats, however, suggests that the normal glomerular comparable with the correlations obtained in
filter actually may leak albumin at higher levels than previous studies. There was a slight correlation of
previously thought, and albuminuria may result from Cystatin C with urea (r=0.513).
failure of the proximal tubule cell retrieval pathway
(Russo et al., 2007). Microalbuminuria may prove to From the research, it was discovered that patient
be a useful marker of AKI and concomitant with high serum creatinine had high urine protein,
proximal tubular cell damage. Microalbuminuria has with microalbuminuria, although some patient with
previously been reported with short- and long-term mild proteinuria never indicated any form of
administration of nephrotoxic chemotherapeutics microalbuminuria, some authors pointed out, that
such as cisplatin, ifosfamide, and methotrexate dipstick tests only measure albumin, which is a more
(Kern et al., 2000 and Koch et al., 1998), as well as specific indication of glomerular injury, such as is
antibiotics such as gentamicin (Tugay et al., 2006). seen in HIVAN (Kimmel, 2003). People with kidney
Using microalbuminuria as a marker, Leven et al. disease localized in the renal tubule may have mild
(2007) demonstrated that N-acetylcysteine may proteinuria composed of other proteins but rarely of
attenuate contrast-induced glomerular and tubular albumin. Thus, dipstick tests are an unreliable way
injury. Microalbuminuria, however, may also be to screening for renal tubular injuries such as the
caused by vigorous exercise, haematuria, urinary Fanconi-like syndrome that tenofovir can cause.
tract infection, and dehydration. Risk factors associated with HIV were also strongly
and independently associated with higher Cystatin C
Widely available, urine tests that screen for level, including lower CD4 lymphocyte count,
proteinuria and albuminuria, have been shown to which is indicative of immune dysfunction. This
identify people at higher risk of kidney disease and suggests that in addition to the adverse metabolic
other adverse outcomes in the general population effects of HIV, severity of HIV infection and
and in people living with HIV. However, a recent coinfection may exacerbate the diminished kidney
study has found that the sensitivity of the cheapest, function observed in these participants. Among the
simplest method of screening for proteinuria, the subjects, those that had higher creatinine and
dipstick test, may be affected by urinary Cystatin C also had proteinuria few with
concentration (Siedner et al., 2008). microalbuminuria which is indicative of
significantly reduced renal function. The result of
There was high correlation (r = 0.876) between the present study showed a high sensitivity of
CysC and SCR that supports the concept that CysC Cystatin C and creatinine in assessing renal function
and SCR have similar properties as plasma markers over other analyte like, urea, proteinuria and
of GFR (Newman et al., 1994). Correlation of Cys C microalbuminuria which are late makers.
measurements with measurement of GFR has been
reported in a number of previous studies (Newman
et al., 1995 and Nilsson-Ehle, 1994). Grubb et al.

Conclusion
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Original Research
SJMLS-2(1)-2017-018
Evaluation of Ovarian Reserve in Assisted Reproductive Facilities;
Biochemical and Other Alternatives: Pros and Cons-A Review Article
Biliaminu, S.A.*1,3, AbdulAzeez, I.M.1, Okesina, A.B.1, Olatinwo, A.W.O. 2,3, Omokanye, L.O. 2,3,
Adunmo G. O.4
Department of Chemical Pathology and Immunology1, Department of Obstetrics and Gynaecology 2, Assisted
Reproductive Therapy Unit 3, Department of Medical Biochemistry, University of Ilorin, Ilorin, Kwara State,
Nigeria 4.
Author for Correspondence *: drbiliaminu@gmail.com/+234-806-088-5920
Abstract breastfeeding or postpartum amenorrhoea (WHO,

The precarious rate of infertility has become a global 2013). Primary infertility is infertility in a couple
issue. The social and psychological stresses
who have never had a child while secondary
attached to the problem of not having a fruit of
infertility is failure to conceive following a previous
womb have necessitated the establishment of
pregnancy. Infertility may be caused by infection in
assisted reproductive facilities within and outside
Nigeria. Most of these Centers are privately owned the man or woman, but often there is no obvious
while very few of them belonging to government. underlying cause. Various other definitions however
The need for the knowledge or idea of ovarian abound with little or minimal differences. For
reserve in female clients of fertility centers is very example, one definition of infertility that is
crucial as it will not only tell the suitability of the frequently used in the United States by reproductive
client for the procedure but also assist in endocrinologists, doctors who specialize in
determining the drugs required for stimulation and infertility, to consider a couple eligible for treatment
the protocol required in a particular client. Various
is:
methods are being used in evaluation of ovarian
reserve in assisted reproductive facilities some of
 A woman under 35 years of age who has not
which are biochemical, ultrasonographic,
histopathologic and combined in nature and form. conceived after 12 months of contraceptive-free
This review article is on evaluation of ovarian intercourse. Twelve months is the lower
reserve in assisted reproductive facilities; reference limit for Time to Pregnancy (TTP) by
biochemical and other alternatives as well as their the World Health Organization (NICE, 2013).
pros and cons. It was essentially based on
literatures and research works written in English.  A woman over 35 years who has not conceived
after 6 months of contraceptive-free sexual
Keywords: Evaluation, Ovarian Reserve, Assisted
intercourse.
Reproductive Facilities.
These time intervals would seem to be reversed; this

Introduction
is an area where public policy trumps science. The
The World Health Organization defined infertility as
idea is that for women beyond age 35, every month
“a disease of the reproductive system characterized
counts and if made to wait another 6 months to
by the failure to achieve a clinical pregnancy after
prove the necessity of medical intervention, the
12 months or more of regular unprotected sexual
problem could become worse. The corollary to this
intercourse (and there is no other reason, such as
is that, by definition, failure to conceive in women

under 35 isn't regarded with the same urgency as it and research works written in English and it will be
is in those over 35. discussed under the following sub-captions:
The precarious rate of infertility has become a Assisted Reproductive Technology

global issue. The consequences of infertility are Assisted Reproductive Technology (ART) is the use
manifold and can include societal repercussions and of reproductive technology to treat infertility. As at
personal suffering. Advances in assisted today the only application of reproductive
reproductive technologies, such as In-Vitro- technology to increase reproduction include in vitro
Fertilization (IVF), can offer hope to many couples fertilization and its possible expansions.
where treatment is available, although barriers exist
in terms of medical coverage and affordability. The Ovarian reserve
medicalization of infertility has unwittingly led to a This is a term that is used to determine the capacity
disregard for the emotional responses that couples of the ovary to provide egg cells that are capable of
experience, which include distress, loss of control, fertilization resulting in a healthy and successful
stigmatization, and a disruption in the pregnancy. With advanced maternal age the number
developmental trajectory of adulthood (Barratt and of egg cell that can be successfully recruited for a
Cooke, 1993). possible pregnancy declines, constituting a major
factor in the inverse correlation between age and
Infertility may have profound psychological effects. female fertility.
Partners may become more anxious to conceive,
increasing sexual dysfunction (Edelmann et al., The concept of “ovarian reserve” defines a woman’s
1994). Marital discord often develops in infertile reproductive potential as a function of the number
couples, especially when they are under pressure to and quality of her remaining oocytes (Schmidt et al.,
make medical decisions. 2005). The general purpose of ovarian reserve
testing is to assess the quality and quantity of the
The social and psychological stresses attached to the remaining oocytes in an attempt to predict
problem of not having fruit of womb have reproductive potential. The ideal screening test
necessitated the establishment of assisted should be reproducible with low intercycle and
reproductive facilities within and outside Nigeria. intracycle variability and demonstrate high
Most of these centers are privately owned while specificity to minimize the risk of a false-positive
very few of them belongs to government. determination of decreased ovarian reserve in a
woman with normal ovarian reserve (Schmidt et al.,
The need for the knowledge or idea of ovarian 2005).
reserve in prospective female clients of fertility
centers is very crucial as it will not only tell the The main goal of ovarian reserve testing is to
suitability of the client for the procedure but also identify those individuals who are at risk of
assist in determining the drugs required for decreased or diminished ovarian reserve, commonly
stimulation and the protocol required in a particular known as DOR. Although ovarian reserve testing
client. cannot predict the end of one’s reproductive years,
results outside the range expected for a patient’s age
Various methods are being used in evaluation of can encourage the individual to pursue more
ovarian reserve in assisted reproductive facilities aggressive treatment options to achieve pregnancy.
some of which are biochemical, ultrasonographic,
histopathological and even combined in nature and The ovary is generally thought of as an egg bank
form. This review article is on evaluation of ovarian from which the woman draws during her
reserve in assisted reproductive facilities reproductive life. The human ovary contains a
(biochemical and other alternatives) as well as their population of primordial follicles. At 18–22 weeks
pros and cons. It is essentially based on literatures post-conception, the female ovary contains its peak

number of follicles (about 300,000 in the average to central negative feedback from estradiol and
case, but individual peak populations range from inhibin B. With normal ovarian function, a
35,000 to 2.5 million) (American Society for developing cohort of follicles secretes estradiol and
Reproductive Medicine, 2012). The size of the inhibin B, which suppress FSH, keeping it in the
initial ovarian reserve is strongly influenced by normal range. In the setting of a smaller follicular
genetics (American College of Obstetricians and cohort and decreased estradiol and inhibin B levels,
Gynecologists, 2014). Also, elevated androgen an increase in pituitary FSH secretion occurs, which
levels during prenatal development have an adverse can be identified as an elevated early follicular
effect on the early establishment of the ovarian phase FSH level. This higher FSH level stimulates
reserve (American College of Obstetricians and rapid ovarian follicular growth, which results in
Gynecologists, 2014). While there is no known higher estradiol levels as well as a shorter follicular
method for assessing the ovarian reserve of phase and reproductive cycle.
individual women (Schmidt et al., 2005), indirect
determination of ovarian reserve is important in the Women who are 35 years or older who have
treatment of infertility (Te Velde and Pearson, attempted to get pregnant unsuccessfully for 6
2002). months should undergo testing for ovarian reserve.
The most commonly used test to assess this ovarian
Indications for Ovarian Reserve Assessment/Risk reserve is the day 3 FSH test (Ferraretti et al.,
Factors for Diminished Ovarian Reserve 2011). This blood test determines the level of FSH
i. Advanced reproductive age (older than 35 on cycle day 3. Cycle day 3 is chosen because at this
years) time the estrogen level is expected to be low, a
ii. Family history of early menopause critical feature, as FSH levels are subject to a
iii. Genetic conditions (45 X Mosaicism) negative feedback. Thus, any determination of FSH
iv. FMR1 (Fragile X) premutation carrier needs to include the corresponding estradiol level to
v. Conditions that can cause ovarian injury indicate that the FSH level was drawn, when the
(endometriosis and pelvic infection) estrogen level was low. In a patient with infrequent
vi. Previous ovarian surgery (for endometriomas) menstruation, an FSH level and estrogen level could
vii. Oophorectomy be measured at random and is valid if the estrogen
viii. History of cancer treated with gonadotoxic level is low. Generally FSH levels are expected to
therapy or pelvic irradiation be below 10 MIU/ml in women with reproductive
ix. History of medical conditions treated with potential (levels of 10-15 MIU/ml are considered
gonadotoxic therapies borderline), however the exact numbers returned
x. Smoking (American College of Obstetricians will depend on the type of assay used in a particular
and Gynecologists, 2014; Gurtcheff et al., 2011 laboratory.
and Schmidt et al., 2005; Faddy et al., 1992).
With advancing reproductive age, basal serum FSH
Tools for Ovarian Reserve Assessment concentrations increase on days 2–4 of the menstrual
These has been classified as follows: cycle. However, because of the inherent variability
A. Biochemical markers of each reproductive cycle, the basal FSH level can
B. Ultrasonographic methods vary, so a single FSH value has limited reliability
C. Histopathological method and (Nelson, 2013). Moreover, there is variability among
D. Combined tests method. different FSH assays that further complicates the
interpretation of a result. Although basal FSH
A. Biochemical Markers of Ovarian Reserve commonly is used to assess ovarian reserve, and
i. Basal Follicle-Stimulating Hormone high values (greater than 10–20 international
Follicle-stimulating hormone is released by the units/L) are associated with diminished ovarian
pituitary gland in response to gonadotropin-releasing reserve and poor response to ovarian stimulation, the
hormone from the hypothalamus and is also subject test is not predictive of failure to conceive (Kwee et

al., 2004). If FSH values are consistently elevated, a individual. In vitro fertilization protocols take into
poor reproductive prognosis is likely; in contrast, a consideration that lower anti-müllerian hormone
single elevated FSH value in women younger than levels are associated with reduced ovarian response
40 years predicts a lower oocyte yield during IVF to stimulation, and high levels raise concern for a
but does not affect the rate of pregnancy (Hendriks brisk ovarian response to stimulation (Bentzen et al.,
et al., 2004). It has advantage of widespread use but 2013). Although the level of anti-müllerian hormone
low sensitivity and limited reliability. is a good predictor of oocyte quantity, it may not
provide information about egg quality. Thus, young
ii. Basal Estradiol women with low anti-müllerian hormone levels may
Estradiol is released from the ovary during follicular have a reduced number of oocytes but normal, age-
development. The estradiol level is usually low (less appropriate oocyte quality (Nelson et al., 2007).
than 50 pg/mL) on days 2–4 of the menstrual cycle
but demonstrates some cycle-to-cycle variability. One limitation of anti-müllerian hormone level
However, an elevated value (greater than 60–80 testing is the variability of results between the
pg/mL) in the early follicular phase can indicate available assays and the inability to compare anti-
reproductive aging and hastened oocyte müllerian hormone levels when different assays are
development. Through central negative feedback, a used. Therefore, in clinical practice, individual anti-
high estradiol level can suppress an elevated FSH müllerian hormone level test results must be
concentration into the normal range, so the value of interpreted based on the reference limit/interval of
obtaining an estradiol level is that it allows the the assay used, and standard cut-off points may
correct interpretation of a normal basal FSH level. differ based on the assay (Toner et al., 2013). Anti-
Basal estradiol has low predictive accuracy for poor müllerian hormone level testing is a useful screening
ovarian response and failure to conceive; therefore, test in women at high risk of diminished ovarian
this test should not be used in isolation to assess reserve and in women undergoing IVF but has
ovarian reserve (Roberts et al., 2005). limited benefits in someone at low risk of
diminished ovarian reserve (Toner et al., 2013).
iii. Anti-Müllerian Hormone
Anti-müllerian hormone is a glycoprotein hormone With further research, anti-müllerian hormone level
that is produced by the granulosa cells of primary, testing may become increasingly valuable in
preantral, and antral follicles 2–6 mm in diameter; assessing ovarian reserve for young women with
thus, it reflects the size of the primordial oocyte pool cancer (American Society for Reproductive
(Ferraretti et al., 2011). Because early follicles Medicine, 2012). Measuring anti-müllerian hormone
secrete anti-müllerian hormone in a gonadotropin- levels before and after chemotherapy allows
independent state, the anti-müllerian hormone detection of differences in ovarian toxicity among
concentration is fairly stable within and between chemotherapy regimens and may help evaluate long-
menstrual cycles (Broekmans et al., 2006). As the term ovarian function (Peigne and Decanter, 2014
number of ovarian follicles decreases with age, a and American Society for Reproductive Medicine,
concomitant decrease in anti-müllerian hormone 2012). Further research on anti-müllerian hormone
levels occurs, which reflects this age-related oocyte may enable assessment of ovarian reserve before
depletion (Tsepelidis et al., 2007). Although an and after ovarian surgery and for women at high risk
undetectable anti-müllerian hormone level suggests of primary ovarian insufficiency; this research may
diminished ovarian reserve and can identify provide an accurate method of predicting the
individuals at risk of poor ovarian response to reproductive lifespan and the timing of menopause
stimulation, undetectable and low anti-müllerian (Broekmans et al., 2006).
hormone levels (0.2–0.7 ng/mL DSL ELISA) are not
predictive of failure to conceive (Bentzen et al., iv. Inhibin B
2013). Furthermore, anti-müllerian hormone levels Inhibin B is a glycoprotein hormone that is secreted
may allow treatment to be tailored to each primarily by pre-antral and antral follicles. The

serum concentration of inhibin B decreases with the and explain the results (Toner et al.,2013). Although
age-related decrease in the number of oocytes. these tests are used commonly by women at low risk
Inhibin B has central negative feedback that controls of diminished ovarian reserve, the results may
FSH secretion; therefore, a decrease in inhibin B provide false reassurance or raise unnecessary
levels leads to increased pituitary FSH secretion and concern.
higher early follicular FSH levels. However, there is
significant variability in inhibin B levels between B. Ultrasonographic Method
menstrual cycles. This marker does not reliably i. Antral Follicle Count
predict a poor response to ovarian stimulation and, The antral follicle count records the number of
thus, is not a recommended test (Nielsen et al., visible ovarian follicles (2–10 mm mean diameter)
2013). It is very sensitive with little reliability. that are observed during transvaginal
ultrasonography in the early follicular phase (cycle
v. Clomiphene Citrate Challenge Test days 2–5). The number of antral follicles correlates
The clomiphene citrate challenge test (CCCT) is with the quantity of remaining follicles and with the
performed by measuring serum FSH on cycle day 3, ovarian response during controlled ovarian
administering 100-mg clomiphene citrate daily on stimulation, and good intercycle and inter observer
cycle days 5–9, and again measuring serum FSH on reliability has been demonstrated (Nielsen et al.,
cycle day 10. In women with a reduced number of 2013 and Tsepelidis et al., 2007). A low antral
ovarian follicles, lower estradiol and inhibin B follicle count is considered 3–6 total antral follicles
production leads to less central negative feedback of and is associated with poor response to ovarian
FSH secretion and an elevated FSH level after stimulation during IVF, but it does not reliably
clomiphene stimulation. Therefore, an elevated FSH predict failure to conceive; in a meta-analysis, a low
level on day 10 of the clomiphene citrate challenge antral follicle count was a mean of 5.2 (2.11
test is suggestive of diminished ovarian reserve. standard deviation) total antral follicles (Tsepelidis
However, there is cycle-to-cycle variability in et al., 2007). There are limited data on the predictive
ovarian biomarkers (estradiol, inhibin B, and FSH) capacity of antral follicle count for IVF patients, so
during the clomiphene citrate challenge test, which it should not be the sole criterion used to plan
limits the reliability of this provocative test. The treatment (Toner et al., 2013). When antral follicle
stimulated FSH level on cycle day 10 of the count was compared with age, basal FSH, basal
clomiphene citrate challenge test is predictive of estradiol, antimüllerian hormone, inhibin B, and
poor ovarian response but is not predictive of failure ovarian volume, antral follicle count and
to conceive (Jayaprakasan et al.,2010). Compared antimüllerian hormone were the most significant
with the basal FSH level and the antral follicle predictors of poor response to ovarian stimulation
count, the cycle-day-10 FSH level does not improve but were not predictive of failure to conceive
the prediction for poor ovarian response (Nielsen et al., 2013).
(Jayaprakasan et al.,2010). Therefore, the use of this
test to assess ovarian reserve is not recommended ii. Ovarian Volume
(Jayaprakasan et al.,2010). It has higher sensitivity The calculation of ovarian volume requires ovarian
than basal FSH but less reliable. measurements in three planes and the use of the
formula for the volume of an ellipsoid: D1 × D2 ×
vi. Home Fertility Tests D3 × 0.52. Some ultrasound software may calculate
Available home fertility tests use a urine sample to this value automatically. Mean ovarian volume, the
assess the FSH level on cycle day 3. These tests are average volume calculated for both ovaries from the
marketed directly to consumers and claim high same individual, is the value used to assess ovarian
accuracy in determining a woman’s ability to reserve. With age, changes in ovarian volume are
conceive. The limitations of these tests include concordant with the age-related decrease in ovarian
misinterpretation of instructions and results and the follicles. Although ovarian volume correlates with
unavailability of a medical professional to interpret ovarian response to stimulation, it does not predict

failure to conceive (Tsepelidis et al., 2007). When women and multiple biopsies from different sites in
screening for diminished ovarian reserve with another two patients, all of them from women
imaging, ovarian volume has limited value having diagnostic laparoscopy for infertility. They
found large variation between the ovaries and
C. Histopathological Method between the sites of the biopsies compared with
antral follicle count for detection of diminished
Ovarian Biopsy ovarian reserve (Qu et al., 2000).
Ovarian reserve depends on the number of
primordial follicles in the ovarian cortex. It was D. Combined Ovarian Reserve Tests
suggested that determining the follicular density A variety of biochemical and imaging techniques
directly by obtaining ovarian biopsy might be more can be used to evaluate ovarian reserve. Because
accurate than current indirect biochemical and no single assessment of ovarian reserve has
ultrasonic tests, especially for women in the later 100% sensitivity and specificity, tests often are
stage of their reproductive life. combined in an attempt to improve the
The pool of primordial follicles in the ovary or prediction of poor outcomes. Anti-müllerian
òvarian reserve' is a major factor in human fertility hormone and antral follicle count are the most
potential. The ageing ovary is characterized by accurate predictors, but combinations of a few
reduction of the number of primordial follicles, and tests are only slightly better than a single test.
this loss accelerates in the late 30s and precedes the Because of the heterogeneity of the tests and cut-
menopause by 10±12 years (Hendriks et al.,2006). off points used in research studies, models of
The definite pool of primordial follicles is relevant combined ovarian reserve tests do not
in two major aspects: (i) the fertility potential of significantly improve the ability to predict poor
women especially in the later part of their reproductive outcomes over single ovarian
reproductive life; and (ii) in women suffering from reserve tests (Toner et al., 2013). Furthermore,
malignant disease who are going through ovarian the use of multiple ovarian reserve tests may
biopsies collection as a potential measure to complicate the understanding of an individual’s
preserve their fertility capacity. For these women,
ovarian reserve and increase the expense of
not only the presence of follicles but their location
screening. Further research is needed to
and whether they exist in the preserved biopsies are
determine an optimal combination of tests. An
important. Ovarian biopsy has been suggested to be
improved understanding of the genetic basis of
considered as part of infertility evaluation
ovarian aging may enable the development of a
(Richardson et al 1987).
panel of genetic tests for routine screening for
In recent years, intensive research has been
ovarian aging.
conducted to try to predict the ovarian reserve, in
particular before embarking on fertility treatment.
Suggestions, Recommendations and
Randomized or `blind' single biopsy is adequate if
Conclusions
follicles are evenly spread in the ovarian cortex (in
Based on the available data and expert opinion, the
any case, they are not deeper than 2 mm from the
American College of Obstetricians and
surface (Amil, 2004). The distribution of follicles
Gynecologists offers the following suggestions,
was extremely uneven in ovarian tissue. A large
recommendations and conclusions:
variation in follicle numbers was observed in
ovarian tissue samples from patient to patient.
 Ovarian reserve testing should be performed for
Furthermore, even though some tissue samples were
women older than 35 years who have not
originally obtained from the same patient, the
conceived after 6 months of attempting
number of follicles counted in one sample of ovarian
pregnancy and women at higher risk of
tissue did not match the number found in another
diminished ovarian reserve, such as those with
tissue sample (Kohl et al., 2000 and Amil, 2004).
a history of cancer treated with gonado-toxic
compared samples of contralateral ovaries from

therapy, pelvic irradiation, or both; those with of achieving a live birth in a single reproductive
medical conditions who were treated with cycle).
gonadotoxic therapies; or those who had Conclusively, the primary goal of ovarian reserve
ovarian surgery for endometriomas. testing is to identify women at risk of decreased
or diminished ovarian reserve with a secondary
 For general Obstetrician–Gynecologists, the goal of individualizing treatment strategies for
most appropriate ovarian reserve screening tests each woman. Although these tests may predict
to use in practice are basal follicle-stimulating ovarian response to infertility treatment, they do
hormone (FSH) plus estradiol levels or not reliably predict failure to conceive (Roberts
antimüllerian hormone (commonly known as et al., 2005 and Schmidt et al., 2005).
AMH) levels. An antral follicle count,
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Original Research
SJMLS-2(1)-2017-019
Influence of Tablet Shape, Size and Colour on Patients Acceptability
Musa Sirajo 1*, Abdullahi Umar 1
Department of General Studies, College of Nursing and Midwifery Sciences, Sokoto 1
Corresponding Author*: sarki4real@ymail.com/+234-803-804-9157/ +234-803-229-4897
Abstract Tablets and Capsules are widely manufactured and

This study was carried out in order to examine the prescribed compared to syrups, injections, herbals
influences of tablet shape, size and colour on
and they provide a number of advantages over other
patients’ acceptability. One hundred and ten (110)
dosage forms; ease of storage, portability and ease
patients were chosen through random sampling
technique in Specialist Hospital Sokoto for this
of administration. According to Kavitha et al.
study. The patients were interviewed using a (2013), the oral route remained the best
questionnaire with ten unique questions in an administration route of therapeutics agents for its
understandable dialect. Data collected were ease of ingestion, pain avoidance and versatility,
analyzed in a tabular form and percentages were hence fast dissolving tablets become an emerging
calculated. It was recorded that 27% of the patients trend in the pharmaceutical industry. Fast dissolving
interviewed complained of various difficulties while tablets are ideal for all types of people, including
swallowing tablet while 73% do not experience any people who have swallowing difficulties, pediatric,
difficult. A significant 80% of subjects prefer either
geriatric and bedridden patients. Despite the fact that
flat circular shape tablet or oblong/oval shape tablet
difficulties in swallowing tablets seem to be a well-
and 20% prefer both shapes. Moreover 65% of them
prefer small size tablet and 35% prefer either
known problem among patients, only few and
medium size, big size or both sizes and 73% dislike desultory investigations have been made on the
big size tablet. Of the subjects studied, 56% prefer subject. In a questionnaire-based study done by
white colour tablet and 26% confirmed that they are General Practitioners in Norway, it was found that
willing to accept any colour given to them while 42% every third woman and every sixth man agreed to
of them dislike yellow colour tablet. Also, 12% dislike have problems in swallowing tablets (Overgaard et
red colour tablet and 14% dislike green colour tablet. al., 2001). Swallowing tablets are not comfortable
for many patients due to physical and psychological
Keywords: Tablet, patient, size, shape, colour,
factors involved. If a patient has once experienced a
swallow and acceptability
tablet sticking in the oesophagus the patient may get
unpleasant associations by swallowing tablets
Introduction
thereafter. A rugged surface makes the tablet scratch
A pharmaceutical tablet is defined as a compressed
the oesophagus during passage and some tablets
solid unit dosage form of medicament containing a
might have bad taste or smell, therefore making the
drug or a mixture of drugs with or without
intake of the tablet a discomforting experience to the
pharmaceutical excipients (Pharmainfo, 2014).
patient and this might consequently, lead to non-
According to pharmacopeia, tablets are solid dosage
compliance (Andersen et al., 1995).
forms containing medicinal substance with or
without suitable diluents.
In recent years, Andersen et al. (1995) reveal that
damage of oesophagus by retention of tablets has

been reported beyond causing discomfort and pain, groups which comprised four (4) Male groups and
but the mucous membrane may be irritated and the another four (4) groups for Female and the
underlying tissue damaged. remaining groups were mixed. Qualitative interview
method was used for data collection. A random
A previous study by Overgaard and Colleagues sampling technique was utilized. A minimum of five
(2001) reported that the ability of tablet to pass (5) male and five (5) female patients were
through the esophagus is assigned to size, shape, interviewed in each mixed group and maximum of
surface area and coating, it is generally agreed that ten (10) patients were interviewed in each identical
the most important factor is size which should be as gender group. The instrument is valid and reliable
small as possible with the correspond weight because the patients were given free hand to make
(Wamberg, 1988). Oblong/oval tablets pass well their comment without any fear or coercion. The
than circular tablets and arched tablets pass well data collected was analyzed using basic statistics
than flat, the stickiness of the tablet surface is also and results was expressed as percentages.
important and the tendency to stick increases with
the tablet surface area of the tablet and coated tablets Results and Discussions
are usually less sticky than uncoated tablets A total of 110 patients consented to participating in
(Overgaard et al., 2001). the study. Of the subjects, 68% were in the 10 years
to 40 years age group while 42% were in the
Sallis and Buckales (1984) found that patients’ 41years to 70 years age group. Gender distribution
acceptance of tablets and their compliance are indicated the 55% of the patients are male and 45%
related to the visual appearance of the tablet, thus, were female. Ethnic distribution os subjects
the importance of both size and colour has been indicated that 87% were from Sokoto state, 3% were
investigated. Blue tablet is generally categorized as from Kebbi, 3% were from Zamfara, 2% were from
depressant or tranquillizing whereas yellow and red Osun state while Kaduna, Niger, Nasarawa, Ekiti,
are categorized as stimulating or antidepressant, and and Kwara states accounted for 1% each. Among the
that red and black capsules were judged to be more subjects studied, 62% of them can only swallow 1 –
powerful than blue, green, orange and yellow ones, 4 tablets daily if they have the choice while 38% of
while white capsules are less powerful (Buckalew them can only swallow 5 tablets and above daily if
and Coffield, 1982). Similarly, Luscher (1992) given the choice. Based on challenges with
found that the colour of tablet is of great importance swallowing of tablets, 27% of the patients
for a successful treatment of patients and that patient complained of various difficulties while swallowing
found the colour corresponding to the expected tablet while 73% of them did not complain of any
therapeutic effect. Also, it has been argued that the difficulty while swallowing tablet. Table 1 shows
patients’ age might influence problems associated the preference among the subjects based of the
with swallowing tablets. Most investigators have shape of the tablets. Table 2 shows the distribution
found that elderly people report more difficulties in of Tablet shape that patients dislike. Table 3 shows
swallowing tablets than younger people (Overgaard the distribution of subjects based on the Size of the
et al., 2001). However, Andersen et al. (1995) found tablet that they like. Table 4 shows the distribution
that people older than 70 years had fewer problems of subjects based on the Size of the tablet that they
than younger people. dislike. Table 5 shows the distribution of subjects
based on Colour of tablet that they like.
Methodology
This study involved a total of One Hundred and Ten
(110) patients attending the Specialist Hospital
Sokoto. Subjects were categorized into eleven (11)

Table 1: Preference among subjects based on the shape of Tablets

Tablet shape patients like Frequency Percentage
Flat circular 44 40
Oblong/Oval 44 40
Both shapes 22 20
Total 110 110
Table 1 shows, that 40% of the patients prefer flat while 40% of them prefer oblong/oval shape tablet
circular shape tablet, according to them the shape is because they find it suitable and easier to swallow
familiar and serves as a common shape of tablets and 20% of them like both shapes.
Table 2: Distribution of Tablet shape that patients dislike

Tablet shape patients dislike Frequency Percentage
Flat circular 45 41
Oblong/Oval 43 39
None of the above 22 20
Total 110 100
Table 2 shows that, 41% of the patients dislike flat dislike oblong/oval shape tablet because they can
circular shape tablet, because they experience some only swallow it when they divide it into two while
difficulties while swallowing it and 39% of them 20% of the patients dislike none of the shapes.
Table 3: Distribution of subjects based on the Size of the tablet that they like
Size of the tablet patients like Frequency Percentage
Small 71 65
Medium 19 17
Big 3 3
All of the above 17 15
Total 110 100
Table 3 shows that, 65% of the patients prefer small them prefer big size tablet and 15% of the patients
size tablets because they find it easier to swallow has no choice of size, which means they can
while 17% of them like medium size tablets, 3% of swallow any size of tablets.
Table 4: Distribution of subjects based on the Size of the tablet that they dislike
Size of the tablet patients dislike Frequency Percentage
Small 7 6
Medium 3 3
Big 80 73
Total 110 100
Table 4 shows that, 73% of the patients dislike big swallowing it and some patients added that they can
size tablet because they find some difficulties while only swallow it when they divide it while 6% of

them dislike small size tablet, 3% of them dislike the size.

medium size tablet and 18% of them dislike none of
Table 5: Distribution of subjects based on Colour of tablet that they like

Colour of tablet patients prefer Frequency Percentage
White 61 56
Red 11 10
Green 3 3
Yellow 6 5
Blue 0 0
Any colour 29 26
Total 110 100
Tablet 5 shows that 56% of the patients prefer white tablets are sweeter, 3% of them prefer green colour
colour tablet, according to them white colour is tablet, 5% of them prefer yellow colour tablet and
suitable and more comfortable than other colours, 26% of them can accept any available colour while
while 10% of them like red colour tablet; according (0%) choose blue colour tablet.
to them because of their belief that some red colour
Table 6: Distribution of subjects based on Colour of tablet that they dislike

Colour of tablet patients dislike Frequency Percentage
White 3 3
Red 13 12
Green 16 14
Yellow 46 42
Blue 2 2
Total 110 100
Table 6 shows that, 3% of the patients dislike white We observed that 27% of the patients complained of
colour tablet, 12% of them dislike red colour tablet, difficulties swallowing tablet while 73% of them do
14% of them dislike green colour tablet and 42% of not experience any difficulty. Difficulties in
the patients dislike yellow tablet. From the swallowing tablets seems a well-known problem
perception of the subjects, all yellow colour tablet among patients (Navarro, 2000). Our finding in this
are bitter and they are difficult to swallow, 2% of study is consistent with a previous report by General
them dislike blue colour tablet and 27% of them Practitioners in Norway which indicated that every
dislike none of the colours. third woman and every sixth man agreed to have
problems in swallowing tablets (Overgaard et al.,
Discussion and Conclusion 2001). Swallowing tablets are not comfortable for
According to Kavitha et al. (2013), the oral route many patients due to physical and psychological
remained the best administration route of factors involved. If a patient has once experienced a
therapeutics agents for its ease of ingestion, pain tablet sticking in the oesophagus the patient may get
avoidance and versatility, hence fast dissolving unpleasant associations by swallowing tablets
tablets become an emerging trend in the thereafter. A rugged surface makes the tablet scratch
pharmaceutical industry. In this present study, we the oesophagus during passage and some tablets
investigated the influences of tablet shape, size and might have bad taste or smell, therefore making the
colour on patients’ acceptability. intake of the tablet a discomforting experience to the

patient and this might consequently, lead to non- importance of both size and colour has been
compliance (Andersen et al., 1995). investigated. Blue tablet is generally categorized as
depressant or tranquillizing whereas yellow and red
We observed that a significant number of subjects are categorized as stimulating or antidepressant, and
(62%) prefer less number of tablets a day (up to 4 that red and black capsules were judged to be more
tablets) compared to 38% who prefer higher powerful than blue, green, orange and yellow ones,
numbers of tablets (5 – above tablets). Our finding is while white capsules are less powerful (Buckalew
consistent with a previous report (Ickovics and and Coffield, 1982). Similarly, Luscher (1992)
Meisler, 1997) which indicated that factors such as found that the colour of tablet is of great importance
as pill burden, regimen complexity, side effects, for a successful treatment of patients and that patient
duration of needed treatment, and dosing schedule found the colour corresponding to the expected
can affect adherence to therapy. therapeutic effect. Also, it has been argued that the
On the preferred shape of tablets, we observed that patients’ age might influence problems associated
flat circular shape tablet and oblong/oval shape with swallowing tablets. Most investigators have
tablet was more preferred. Our finding is in found that elderly people report more difficulties in
agreement with a previous report (Overgaard et al., swallowing tablets than younger people (Overgaard
2001) which indicated that oblong/oval tablets is et al., 2001). However, Andersen et al. (1995) found
well preferred by patients because they pass well that people older than 70 years had fewer problems
than circular tablets and arched tablets pass well than younger people.
than flat tablets. The stickiness of the tablet surface
is also important and the tendency to stick increases In conclusion, this study has shown that some
with the tablet surface area of the tablet and coated patients have difficulties while swallowing tablet,
tablets are usually less sticky than uncoated tablets. that most patients prefer less number of tablets daily,
small sized, flat circular and oblong/oval shaped
We observed that majority of subjects 65% preferred tablets and white coloured tablets.
small sized tablets compared to 35% who preferred
medium size, big size or both sizes. Our finding is in Recommendations
agreement with a previous report (Overgaard et Based on the findings of this study, the following
al.,2001) which indicated that the ability of tablet to recommendations are given:
pass through the esophagus is assigned to size,  The size of a tablet should be made as small as
shape, surface area and coating, it is generally possible to facilitate swallowing and adherence.
agreed that the most important factor is size which  The big size tablet should be replaced with
should be as small as possible with the correspond medium size or coated with fruit flavor so that a
weight (Wamberg, 1988). In recent years, Andersen patient can swallow the tablet with ease.
et al. (1995) reveal that damage of oesophagus by  Yellow colour tablet should also be coated
retention of tablets has been reported beyond because majority of the patients regards it as
causing discomfort and pain, but the mucous bitter colour
membrane may be irritated and the underlying tissue References
damaged. Ardersen, O., Zweidorff, O., Hjelde, T., et al.
(1995). Problems in
With regards to the colour, we observed that swallowing tablets. Journal of Tidsskr nor
majority (56%) of subjects preferred white colour Lageforen nr; 115: 947 – 949.
tablet while (42%) of them dislike yellow colour Buckalew, L.W. and Coffield, K.E. (1984). An
tablet and (2%) dislike blue colour tablet. Our Investigation of drug expectancy as a
finding is consistent with previous report (Sallis and function of capsule colour, size and preparation
Buckales, 1984) which indicated that patients’ form. Journal of Clinical Psychopharmacology;
acceptance of tablets and their compliance are 4: 244 – 245.
related to the visual appearance of the tablet. The

Ickovics, J.R., Meisler, A.W. (1997). Adherence in www.pharmacopeia.cn/v29240/usp29nf24s0_c

AIDS clinical trials: a framework for clinical 1151s87.html on 23- Feb - 2017.
research and clinical care. Journal of Clinical Pharmainfo.net (2014). What is pharmaceutical
Epidemiology;50(4):385-391. tablet Retrieved from
Kavitha, K., Kuthama. S., Hui, B.J. et al (2013). www.pharmainfo.net/pharmaceutical-tablet on
Potential drug candidates for fast dissolving 20 - Feb – 2017.
drug delivery - A review. Research Journal of Sallis, R.E. and Buckalew, L.W. (1984). Relation of
Pharmaceutical, Biological and Chemical Capsule colour and Perceived Potency. Journal
Sciences; 4: 1510 – 1526. of Perceptual and Motor Skills ; 58: 897 – 898.
Luscher, M. (1992). The psychological influence of Navarro, V. (2000). Improving medication
capsule colours on the therapeutic effect of a compliance in patients with depression: Use of
drug. News Sheet. Capsugel Library Bornem, orodispersible tablets. Advanced
Belgium. Therapy;27(11):785–795.
Overgaard, A.B.A., Hojsted, J., Hansen, R., et al. Wamberg, T. (1988). Does it have to be difficult
(2001). Patients’ evaluation of shape, size swallowing tablets? Farmaceutisk Tidende; 42:
and colour of solid dosage forms. Journal of 686 – 690.
Pharmacy World and Science; 23:185 – 188.
Pharmacopeia (2017). Pharmaceutical tablet
definition Retrieved from


Original Research
SJMLS-2(1)-2017-020
Effect of Methanol Leaves Extract of Cordia africana on Serum Total
Protein, Albumin, Globulin and some Haematological Indices in
Alloxan-Induced Diabetic Wistar Rats.
Tanko, Y. * 1, Gidado N.M. 1, Mohammed, K.A. 2, Abdulrazak, A. 2, Yusuf, R. 3
Department of Human Physiology, Ahmadu Bello University, Zaria, Nigeria1, Department of Human
Physiology, Kaduna State University, Nigeria 2, Department of Chemical Pathology Ahmadu Bello
University, Zaria, Nigeria 3.
Corresponding author*: yusuftanko@abu.edu.ng/+234-803-705-4274
Abstract when compared with the diabetic control

The aim of the study was to determine the untreated. Furthermore, there was a significant
effects of methanol leaves extract of Cordia increase in the white blood cell and lymphocyte
africana on serum total protein, albumin, counts as compared with the control. With
globulin and some haematological indices in regards to the platelet count, there was a
alloxan induced diabetic Wistar Rats. Rats significant (p<0.05) decrease as compared with
weighing between 120-150g were induced the control diabetic untreated rats. In relation to
intraperitoneally with alloxan 150 mg/kg. The the reference drug there was a significant
rats were grouped into six groups of five (p<0.05) decrease when compared with the
animals per group. Group 1 is the control diabetic untreated. Furthermore, in
normoglycaemic control group, Group 2 served relations to the serum levels of total protein
as the diabetic negative control, Group 3 albumin and globulin, there was a significant
served as positive control and was treated with (p<0.05) increase when compared with the
Glibenclamide. Group 4, 5 and 6 were treated diabetic control untreated. The preliminary
with 100, 200 and 400 mg/kg body weight of phytochemical screening of the of the methanol
methanol leaf extract of Cordia africana extracts revealed the presence of Tannins
respectively. The extracts were given to the Saponins Flavonoids Alkaloids, Cardiac
animals orally for a period of 4 weeks. At the glycosides Cyanogenic glycosides Resins
end of the experimental period, the rats from Steroid/Terpenoids and Carbohydrates . The
each experimental group were sacrificed and LD50 was greater than 5000 mg/kg orally. In
the blood samples were collected for the conclusion methanol leaf extract of Cordia
determination the haematological indices and africana have possible stimulatory effect on red
the serums were used for the determination of blood cell production as a possible
protein, albumin and globulin. There was a haematopoietic agent with the potential of
significant (p<0.05) increase in the packed cell ameliorating the burden of anemia and
volume when compared with the control diabetes.
diabetic untreated. In addition there was a
significant increase in the mean corpuscular
volume, mean corpuscular haemoglobin and
mean corpuscular haemoglobin concentration

Keywords: Cordia africana, Alloxan, Total The aim of this study was to determine the effect of
protein, Albumin, Globulin, Haematological methanol leaves extract of Cordia africana on serum
Indices total protein, albumim, globulin and some
haematological indices in alloxan induced diabetic
Introduction Wistar rats.
Diabetes is a common metabolic disorder
characterized by hyperglycemia due to an absolute Materials and Methods
or relative insulin deficiency (WHO, 2010 and Collection Material
Lawal et al., 2008). It affects essential biochemical Fresh leaves of Cordia africana were collected from
pathways of the body including carbohydrate, Basawa Town, Sabon-Gari Local Government Area
protein, and lipid metabolisms. The World Health of Kaduna State, Nigeria in August, 2016. The plant
Organization (WHO), estimated that there were 171 was authenticated at the Herbarium Section in the
million people in the world with diabetes in the year Department of Biological Sciences, Ahmadu Bello
2008 and this is projected to increase by over a University, Zaria, Kaduna State, Nigeria. A voucher
100% to 366 million by 2030 (WHO, 2010). specimen (No 620) was deposited at the herbarium
Diabetes is associated with reduced life expectancy, for future reference.
significant high mortality and diminished quality of
life. In 2005 an estimated 1.1 million people died Chemical/drug used
from diabetes and diabetes-related complications Alloxan monohydrate was purchased from Sigma
(WHO, 2008). Its prevalence is rising globally, Chemicals (St Louis, U.S.A.). The Glibenclamide
including the rural Nigerian populations (Ime et al., and all chemicals used were of analytical grade.
2011).
Preparation of Extract
Cordia africana is a medium-sized evergreen tree, it The Cordia africana leaves were air dried under
is about 30 meters high, has branches with an shade for twenty-one days and then size-reduced
umbrella-shape. Leaves are alternate, simple, ovate into powder with a pestle and mortar. About 100g of
shape which is about 7.5-17.5 cm long and 3.5-10.2 the powdered leaves was macerated with 500ml
cm broad, it is leathery dark green. Its generic name methanol for 72 hours with occasional shaking. The
was honored to a German Biologist in 16th century. extract was concentrated in vacuo affording a yield
Valerius Cordus," africana" means from Africa, its of 13.6 %. w/w and subsequently referred to as
synonyms 'abyssinica' means the plant was methanol leaves extract of Cordia africana .
described from Ethiopia (Orwa et al., 2009). Solutions of the extract were prepared freshly daily.
English common names for Cordia africana are East
African cordia or large-leafed cordia or Sudan teak Preliminary phytochemical Screening
(Schmidt and Mwaura, 2010). Cordia africana The screening was carried out in accordance with
which is an important indigenous timber tree of the standard protocol as described by Trease and
Ethiopia is a multipurpose tree species. Like many Evans (1983).
deciduous trees, it exhibit repeated branching (Etefa
et al., 2013). It is called alulluba in Hausa language. Acute toxicity study
Fruits have a sweet, edible pulp. The plant provides The lethal dose (LD50) of the plant extract was
bee forage, because the flowers yield a lot of nectar. determined by the method of Lorke (1983) using 12
Beehives are often found in the trees (Tewolde- mice. In the first phase, mice were divided into 3
Berhan et al., 2013). The fresh, juicy bark of groups of 3 mice each and were treated with the
Cordia africana is used to tie a broken bone, this extract at doses of 10, 100 and 1000 mg/kg body
material is replaced occasionally with a fresh one weight orally. They were observed for 24 hours for
until the bone is healed (Tewolde-Berhan et al., signs of toxicity. In the second phase, 4 groups
2013). containing one mouse each were injected with four
more specific doses of the extract orally. The

median lethal dose (LD50) was calculated using the Group 3: Diabetic received Glibenclamide 2
second phase. mg/kg b w for four weeks orally
Group 4: Diabetic and treated with 100 mg/kg b
Experimental animals w methanol leaves extract of Cordia africana for
Thirty (30) Wistar rats of both gender weighed four weeks orally.
between 150-200 g were obtained from the Animal Group 5: Diabetic and treated with 200 mg/kg
House of the Department of Human Physiology, b.w methanol leaves extract of Cordia africana for
Ahmadu Bello University, Zaria, Nigeria. The Rats four weeks orally.
were maintained on standard laboratory animal feed Group 6: Diabetic and treated with 400 mg/kg bw
and water ad libitum, and housed in polypropylene methanol leaves extract of Cordia africana for four
cages at room temperature throughout the study. orally.
These studies were carried out in Ahmadu Bello
University in accordance with the regulations Determination of Blood Glucose Level
governing the use of laboratory animals as accepted Blood glucose level was determined by collection of
internationally. blood sample from the tail artery of the rats by
glucose-oxidase principle (Beach and Turner, 1958)
Induction of Diabetes Mellitus using digital glucometer (Accu-chek Advantage)
The Wistar rats were fasted for about 16-18 h, after and was expressed as mg/dL. Rat with blood glucose
which diabetes was induced by a single levels 200 mg/dl were considered for the study.
intraperitoneal injection of Alloxan monohydrate
dissolved in 0.9% cold normal saline solution at a Blood Sample Collection and Serum Preparation
dose of 150mg/kg body weight (Katsumata et al., After the treatment, all animals were sacrificed
1999). Alloxan produces fatal hypoglycaemia and to using light chloroform and 5 mL of blood sample
prevent this, the rats were treated with 20% glucose were collected into specimen bottles and allowed to
solution orally for 6 hours. After which they were clot and separated by centrifugation at 3,000g for 10
placed on 5% glucose solution for 24 hours minutes using Hitachi Universal 32 Centrifuge
(Dhandapani et al., 2002). Blood was collected from (Hitachi, Germany). The supernatant obtained were
the tail vein of the rats after 72 hours of Alloxan used for the determination of lipid profile and liver
injection. The rats having fasting blood glucose enzymes.
level 200 mg/dl were selected for the study.
Determination of Serum Total Protein, Albumin,
Determination of blood glucose levels Globulin and Albumin-Globulin Ratio
Fasting blood glucose levels were determined by The serum total protein was determined by the
using the glucose oxidase method (Trinder, 1969) Biuret method of Reinhold (1953) using a
with One Touch Basic® Glucometer (Lifescan, Inc. commercial kit (Randox Laboratories Ltd., U.K.).
Milpitas, USA) and results were reported as mg/dl The serum albumin which quantitatively binds
(Rheney and Kirk, 2000). bromocresol green (BCG) to form an albumin-BCG
complex was measured as an endpoint reaction at
Experimental Design 596 nm was determined according to the method of
In the experiment, a total of 30 Wistar rats were Doumas et al. (1971). Globulin was obtained by
used; the animals were randomly divided into six subtracting the albumin from the total protein.
groups of five rats each as follows:
Group 1: Normoglycaemic control and Determination of Haematological Parameters
administered (0.5 ml/kg body weight) The red blood cells (RBC) and white blood cells
distilled water (WBC) counts were determined by the improved
Groups 2: Diabetic control administered (0.5 Neubauer haemocytometer method. The
ml/kg body weight) distilled water haemoglobin (Hb) concentration was determined
according to Jain (1986), using the

Cyanomethaemoglobin method. The packed cell

volume (PCV) was determined by the Statistical Analysis
microhaematocrit method according to Dacie and Data obtained from each group were expressed as
Lewis (1991). Schilling method of differential mean ± SEM. The data were statistically analyzed
leucocyte count was used to determine the using (ANOVA) with Tukey’s post-hoc test to
distribution of the various leucocytes (Mitruka and compare the levels of significant between the control
Rawnsley, 1977). Mean corpuscular volume (MCV), and experimental groups. All statistical analysis was
mean corpuscular haemoglobin (MCH) and mean evaluated using SPSS version 17.0 software and
corpuscular haemoglobin concentration (MCHC) Microsoft Excel (2007). The values of p ≤ 0.05 were
were computed according to Jain (1986). considered as significant.
Results
Table 1: Preliminary phytochemical screening of methanol leaves extract of Cordia africana
Constituents Remark
Tannins +
Saponins +
Flavonoids +
Alkaloids +
Cardiac glycosides +
Cyanogenic glycosides +
Resins +
Steroid/Terpenoids +
Carbohydrates +
Anthraquinone -
Note: + Present, - Absent
Acute toxicity study (LD50) Effect on Serum Total Protein Level

The sign of toxicity was first noticed after 8-10 The results of the study recorded a significant (p <
hours of extract administration. There was decreased 0.05) decrease in the levels of total serum protein of
locomotor activity, decreased feed intake, and diabetic untreated animals when compared with the
prostration after 8 hours of extract administration. normal control group. Treatment of diabetic animals
The median lethal dose (LD50) in rats was calculated with the graded doses of Cordia africana (100, 200
to be greater than 5000 mg/kg body weight orally. and 400 mg/kg) and glibenclamide (2mg/kg),
resulted to a significant (p < 0.05) increase in the
Effect of Cordia africana on Serum Proteins in serum total protein level when compared with the
Alloxan-induced Diabetic Wistar Rats diabetic control group as shown in Table 1.
The results of the study revealed a significant (p <
0.05) decrease in the levels of total serum protein Effect on Serum Albumin Level
of diabetic untreated animals when compared with The results showed that alloxan administration
the animals in the normal control group. Treatment caused a significant (p < 0.05) decrease in the level
of diabetic animals with graded doses of extract of serum albumin in the diabetic untreated animals
(100, 200 and 400 mg/kg) and glibenclamide (2 when compared with normal control rats. However,
mg/kg), resulted to a significant (p < 0.05) elevation administration various doses of Cordia africana
of serum total protein level when compared with the (100, 200 400 mg/kg) and glibenclamide (2 mg/kg),
diabetic control group (Table 1). significantly (p < 0.05) increased the serum albumin
levels when compared with the corresponding
diabetic untreated animals as shown in Table 1.

Effect on Serum Globulin Level (100, 200, 400 mg/kg) and glibenclamide (2 mg/kg)
The results obtained showed that the diabetic produced a significant (p < 0.05) increase of in the
untreated rats had a significantly (p < 0.05) level of serum globulin when compared with
decreased level of serum globulin when compared animals in the diabetic control group as shown in
with the animals in the normal control group Table 1.
Administration of various doses of Cordia africana
Table 1: Effects of Methanol leave extract of Cordia africana on serum total proteins, albumin, globulin,
albumin in Alloxan-induced diabetic Wistar rats
Treatment Groups Serum Total Serum Albumin Serum
Protein (g/L) (g/L) Globulin
(g/L)
Normoglycaemic 68.60 ± 1.31 39.20 ± 0.98 29.20 ± 0.66
Diabetic untreated 39.10 ± 1.60 23.20 ± 1.01 18.30 ± 1.64a
Glibenclamide 68.20 ± 1.22a 37.80 ± 1.09a 31.10 ± 0.32a
2mg/kg
100 mg/kg extract 62.30 ± 1.00a 32.00 ± 1.18a 30.00 ± 1.03a
200 mg/kg extract 58.00 ± 1.22 a 32.20 ± 1.19a 26.20 ± 0.51a
400 mg/kg extract 67.40 ± 1.30a 36.20 ± 1.23a 31.10 ± 2.85a
Table 2: Effects of Methanol leave extract of Cordia africana on Erythrocytes indices in Alloxan-
induced diabetic Wistar rats
Treatment Hb (g/dL) RBC PCV (%) MCV (fL) MCH (pg) MCHC (g/dl)
Groups (×1012/L)
Normoglycaemic 12.84±0.03 6.98±0.25 37.74±2.03 64.58±2.11 21.78±1.14 b 35.20±0.49

Diabetic 7.36± 0.06 4.84±0.20 22.24±2.10 48.11±2.04 14.35±1.05 b 27.22±1.14
untreated
Glibenclamide 11.56±0.02 a 6.75±0.18 a 33.42±1.33 a 53.92±1.15 a 18.20±0.09b 35.59±0.13 a
2mg/kg
100 mg/kg 12.21±0.06 a 6.88±0.21a 35.14±1.10 a 58.22±2.02 a 18.96±0.06 b 37.44±0.25 a
extract
200 mg/kg 11.30±0.04a 6.87±0.26 a 37.23± 1.03 a 66.28±3.21 a 19.78±0.05 b 36.22±1.59 a
extract
400 mg/kg 12.52±0.02 a 7.37±0.19 a 37.54±1.40 a 64.34±2.18 a 18.84±0.03 b 38.05±0.63 a
extract
Table 3: Effects of Methanol leave extract of Cordia africana on Leucocytes indices in Alloxan-induced
diabetic Wistar rats
Treatment Groups WBC (×109/L) Neutrophils Lymphocytes (× Platelets
(×109) 109) Count (×109)
Normoglycaemic 14.26±1.68 3.44±0.19 11.14±1.21 a 386.20±21.21
b
Diabetic untreated 6.70±1.262 1.50±0.13 4.26±1.27 749.60±20.10
Glibenclamide 13.12±1.65a 2.09±0.10a 8.08±1.69c 420.00±22.22a
2mg/kg
100 mg/kg extract 11.08±1.38a 2.42±0.14a 7.64±1.33c 488.80±20.20 a

Discussion into protein and decreased proteolysis by activating

In diabetes, increased blood nitrogenous substances the enzyme that catalyzes amino acids
may be accounted for by the enhanced breakdown of transamination. Also, good correlation between
both liver and plasma proteins (Prakasam et al., protein synthesis and insulin level has been reported
2004). In addition, the reason for the reduction in the (Sayed et al., 2011 and Nahla and Ismail, 2006).
level of albumin could be as a result of the Blood cell morphology, distribution and indices
regulation of albumin catabolism by neonatal Fc such as red blood cells, haemoglobin, packed cell
receptor (FcRn) which binds albumin in acidic volume, platelets, white blood cells count, mean
environments and increases albumin catabolism and corpuscular volume, mean corpuscular haemoglobin
hence, leads to a decreased level of serum albumin and mean corpuscular haemoglobin concentration
(Chaudhury et al., 2003). Proteins have long been are good indicators of systemic response to external
regarded as a principal target for oxidants due to stress (Usama et al., 2013 and Srivastava and
their abundance in biological systems (Medina- Choudhay, 2010). In addition, the knowledge of
Navarro et al., 2010). Serum concentrations of haematological characteristics is an important tool
proteins and albumin can help to show the condition used as an effective and sensitive index of assessing
of the liver and also to ascertain the different types the physiological and pathological changes in
of liver damage (Yakubu et al., 2003). Albumin, the animal models (Zhou et al., 2009). The analysis of
most abundant plasma protein consists of more than blood indices has proven to be a valuable approach
60% of free serum proteins is synthesized and for analyzing the health status of animal models as
secreted by the liver and it has many vital functions these indices provide reliable information on
such as maintaining plasma colloid osmotic metabolic disorders, deficiencies, chronic stress
pressure, anti-oxidation and transportation of metals, status and blood related functions before they are
fatty acids, cholesterol, bile pigments, and drugs present in a clinical setting (Bahmani et al., 2001).
(Nayyar et al., 2012; Shi et al., 2010 and Roche et Alterations in blood parameters may be due to
al., 2008). Serum albumin is a key antioxidant changes in cellular integrity, membrane permeability
agent and its structural modification as a result of of cells or even due to exposure to toxic chemicals
induction by glucose or free radicals can impair its (Hoffbrand and Pettit, 1997).
antioxidant potentials (Faure et al., 2008). It also
represents the key and predominant antioxidant in The lower values of Hb, RBC and PCV in the
plasma, a body compartment known to be exposed alloxan-induced diabetic untreated group in
to continuous oxidative stress (Roche et al., 2008). comparison with those obtained in the normal
A great proportion of total serum antioxidant control rats observed in the present study agreed
properties can be attributed to albumin (Roche et al., with those reported by other researchers (Matough et
2008). Administration with various doses of al., 2012 and Oyedemi et al., 2011). However, the
methanol extract of cordia africana significantly significantly reduced levels of Hb, RBC and PCV in
decreases the serum total protein, albumin and the diabetic animals may be attributed to the
globulin levels when compared to diabetic untreated infections on the normal body systems (Oyedemi et
control. The ability of the extract to normalize the al., 2011). Moreso, reactive oxygen species have
levels of albumin in the hyperglycaemic state may also been implicated in the mechanism of red cells
be attributed to their free radical scavenging damage (Mohammed et al., 2009). Diabetes mellitus
property of the plant extract due to the presences of has been reported to be accompanied by increased
the secondary metabolites as revealed in the production of free radicals (Mohammed et al., 2013
preliminary phytochemical screening. This and Baynes, 1999), which causes damage to cellular
improvement could be attributed to increased proteins, membrane lipids and nucleic acids, and
protein synthesis, increasing incorporation of certain eventually cell death (Oyedemi et al.,2011).
amino acids as a result of increasing insulin Therefore, the anaemia recorded in the present
secretion, increase of hepatic uptake of glucogenic investigation may be sequel to the haemolysis
amino acids, stimulation of amino acid incorporation caused by increased erythrocyte osmotic fragility by

Alloxan-induced hyperglycaemia observed in the Sembulingam, 2013). Furthermore, MCH and

study (Oyedemi et al., 2011). Oxidation of these MCHC have been used as a guide in the
proteins and hyperglycaemia in diabetes mellitus classification of anaemia (Baker and Silverton,
causes an increase in the production of lipid 1985). The significant decrease in these red cell
peroxides that lead to haemolysis of RBC parameters observed in the present study may be due
(Olszewska et al., 2012 and Arun and Ramesh, to iron deficiency; and the RBC in this condition is
2002). However, treatment of diabetic animals with said to be hypochromic (Sembulingam and
all doses of the extract and glibenclamide Sembulingam, 2013). Hence, treatment of diabetic
respectively significantly improved the levels of animals with the extract and glibenclamide
haemoglobin concentration, red cell count and significantly restored changes in MCV, MCH and
packed cell volume when compared with the MCHC values when compared the normal control
diabetic control group. The probable mechanism by group. There was a significant reduction in the total
which the plant extract exerts this effect may be WBC count and its differentials such as
linked to increased protein synthesis or mobilization, lymphocytes and neutrophils. The reduction of these
which is largely produced in the liver as well as parameters could be linked to suppression of
secretion of erythropoietin in the stem cells of the leucocytosis from the bone marrow which may
animals. Erythropoietin is a glycoprotein hormone account for poor defensive mechanisms against
which stimulates stem cells in the bone marrow to infection (Oyedemi et al., 2010). Consequently, they
produce red blood cells (Oyedemi et al, 2011 and might have effects on the immune system and
Ohlsson and Aher, 2006). The stimulation of this phagocytic activity of the animals (Torell et al.,
hormone enhances rapid synthesis of red blood cell 1986). Treatment of diabetic animals with the
which is reflected by increased levels of Hb, red Cordia africana extract produced an ameliorative
blood cell and packed cell volume. Erythropoietin is effect as reflected by significant increase in WBC,
a glycoprotein hormone which stimulates stem cells neutrophlis and lymphocyte counts respectively
in the bone marrow to produce red blood cells when compared with the diabetic control group rats.
(Ohlsson and Aher, 2006). The stimulation of this This is an indication of increased cell mediated
hormone enhances rapid synthesis of RBC and this immunity in the diabetic rats that were administered
often leads to improved level of MCH and MCHC with the extract. Platelets play a role in blood
(Abu-Zaiton, 2010). Hence, the haemopoietic effect clotting, which is a meshwork of fibrin fibres. The
of the extract may probably be on stimulation of fibres usually adhere to any vascular opening and
erythropoietin, thrombopoietin and granulopoietin hence prevent further blood clot. It plays a crucial
production in response to anaemia, role in reducing blood loss and repairing of vascular
thrombocytopenia and leucopenia associated with injury (Oyedemi et al., 2010). It is likely the alloxan
Alloxan - induced diabetes observed in the current administered to diabetic untreated animals induced
investigation. Furthermore, the MCV, MCH and inflammation. Platelet aggregation ability has been
MCHC were significantly decreased in the diabetic reported in diabetes mellitus in chronic
control rats when compared with rats of the normal hyperglycaemia as a result of lack or deficiency of
control group. The alloxan-induced alterations in insulin (Jarald et al., 2008).
MCV, MCH and MCHC have been reported to be
due to direct or feedback responses of structural In conclusion, administration of Cordia africana
damage to RBC membranes resulting in haemolysis methanol extract to diabetic rats produced a
and impairment in haemoglobin synthesis, stress- significantly elevated serum total protein, albumin
related release of RBCs from the spleen and hypoxia and globulin levels. Furthermore, it increases RBC
(Shah, 2006 and Marei et al., 1998). Also, the count, Hb concentration, PCV among diabetic
significant decrease in MCV suggests that the animals treated with the extract, which suggests the
diabetic rats had tendency towards microcytosis, haemopoietic effect which may probably be due
which is a type of anaemia caused by iron deficiency stimulation of erythropoietin. In addition, the
resulting in low RBC volume (Sembulingam and significantly restored changes in MCV, MCH and

MCHC values showed improved anaemic condition characterisation of Cordia africana

observed in diabetic animals and also suggest the population at six provinces in North Ethiopia.
restoration of oxygen carrying capacity of the blood. International Journal of Agricultural Science
and Research; 3(2): 195-206.
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Original Research
SJMLS-2(1)-2017-021
A Prospective Study on Sickle Status and Haemoglobinopathy
Awareness in Ijumu Local Government Area of Kogi State Nigeria.
Olatunbosun, G.D.1*, Ajeneye, F.2, Fredrick, C.3
Bose Specialist Hospital, Ire-Akari, Isolo, Lagos State, Nigeria 1,
Department of Haematology, Kings College Hospital (PRUH), United Kingdom 2,
College of Health Sciences, University of Abuja, Nigeria 3,
Author for Correspondence: phebeola817@gmail.com/ +234-806-211-9804
Abstract response from participants and A chi square test

Sickle Cell Anemia (SCA) has been known in Africa was used to establish the relationship between the
before the twentieth century and the inhabitance variables. Majority (69.0%) of the studied
have given it several names based on their participants were aware of haemoglobin
understanding. About that 5% of the world electrophoretic pattern and 23.6% of the whole
population carries genes responsible for population knew their sickle cell status while 40.3%
haemoglobinopathies (WHO, 2006). The prevalence understood the etiology of sickle cell anaemia as
of this disease is becoming higher, in the society, hereditary. Structured screening programme,
creating more complications despite the difficulties surveillance, health promotion and proper
the people encounter in life. The increasing number counseling remains a big issue in sub-Saharan
of SCA will continue to have a major impact Africa; insufficient awareness and inadequate health
particularly on healthcare services, financing and facilities within the Ijumu Local areas were identified
mortality in affected regions. during this small study. We anticipated that
government intervention and state funding will
This cross-sectional study was carried out among eventually improve and help create awareness of
the subjects selected from Ijumu Local Government Sickle Cell Disease in Kogi State.
area. The Local Government area had a total
population of 119,929 (2006 census) with its Keywords: Sickle Cell Disease,
headquarter at Iyara, Iyara has been one of the 21 Haemoglobinopathy, Awareness, Ijumu Local
Local Governments in Kogi state with a total Government Area, Kogi State, Nigeria.
population estimate of 3,595,796 as at 2005. A
structured questionnaire was designed and initially Introduction
piloted to ensure that respondents could understand
Sickle Cell Anaemia has been known in Africa
the questions and the response format was suitable.
before the twentieth Century and the inhabitance has
It was divided into sections that covered various
given it several names based on their understanding
aspects of the objectives. Using a cluster sampling
technique, 400 questionnaires were distributed and linked the disease with reincarnation (Ogbanije
within seven communities in Iyara, 335 (84%) by Ibo tribe and Abiku by the Yoruba tribe in
questionnaires were returned for this study. The Nigeria). Inheritance of the gene was discovered by
data collected from the questionnaire was entered the contribution to genetics by Gregor Mendel in
into a spreadsheet and analysed using the SPSS 1866, and his principle stated that couples with both
statistical package (SPSS, 2014). Descriptive AS gene will have a 25% chance from each
statistics was used to measure the frequency of the pregnancy to have Hb SS child, 50% chance of Hb

AS and 25% chance of Hb AA child (Karnon et al.,

2006). However, 20 - 40% of Nigerians carry sickle Globally, it is estimated that about 305,000
cell trait Hb AS (Fleming, 1982). Since the newborns are born annually with SCA, and the
discovery of sickle cell disease by Dr J.B. Herrick in global burden has been shown to be on the increase
1904 from the blood of an anaemic West Indian (Piel et al., 2013). The prevalence of Sickle Cell
Medical Student, a lot of new information have been Anaemia is about 20 per 1000 births in Nigeria and
made available about the disease. Studies have SCD is one of the most common single-gene
shown that the genetic basis of the disease is the disorders. About 25% of adults in Nigeria have the
substitution of valine for glutamic acid in position 6 sickle cell gene (Rafi et al., 2007). Moreover,
of the globin chains (Bazuaye et al., 2009). Nigeria has about 150000 children who are born
annually with sickle cell anaemia (Galadanci et al.,
According to World Health Organization (2006), it 2014). Despite recent advances in the management
was reported that 5% of the world population carries of SCD through improved care, re-induction of
genes responsible for haemoglobinopathies and that foetal haemoglobin synthesis, gene therapy and bone
Sickle Cell Anaemia is particularly common among marrow transplantation, the condition continues to
people whose ancestors comes from sub-Saharan cause high morbidity and early death in Africa due
Africa, India, Saudi Arabia and Mediterranean to inadequate resources. The increasing number of
countries. Furthermore, over 300,000 babies are SCA will continue to have a major impact
born worldwide with Sickle Cell Disease; with the particularly on healthcare services financing and
majority of this birth in Africa of which Sickle Cell mortality (Piel et al., 2013). Thus, the need for
Disease is one of the most common genetic disorder. awareness of sickle trait amongst individuals
The prevalence of this disease is becoming higher, through their genotype status remains a priority.
in the society, creating complications and burden on
affected individuals (Oyedele et al., 2015). Research Setting
Prevention of this disease through carrier This study was carried out among the indigenes of
identification and genetic counseling remains an Ijumu Local Government communities which
approach among many intervention, in order to included Iyara, Ekinrin-Adde, Ogidi, Egbeda, Iffe
reduce the impact of this diseases and allow better and Iyamoye. Ijumu is a Local Government area in
use of available resources in the low-income Kogi state, Nigeria having its headquarters in the
countries where the condition is most prevalent town of Iyara. Kogi is a state in the central region of
(WHO, 2006). With an increasing prevalence of this Nigeria. It is popularly called the Confluence state.
disease in Nigeria, there’s need to evaluate the level The target population for this study are community
of awareness, acceptance of premarital dwellers over the age 18 years who were further
haemoglobinopathy screening a way of reducing and grouped into student, unmarried and married
or preventing Sickle Cell Disease (Oyedele et al., subjects.
2015) which further support the research of Bazuaye
et al. (2009), confirmed that there is poor knowledge Ethical Consideration
of sickle cell disease among secondary school The study was guided by ethical principle. Informed
students in Nigeria. A similar study found out that consent was obtained from the participants before
63.7% of university graduate knew there the research commenced, explaining how the data
haemoglobinopathy status (Moronkola et al., 2007). will be used and avoiding the use sensitive
The results might be comparative if this study is information as possible. The approval for this study
extended to the public schools, university students, was obtained from the Hospital Management Board
the urban areas and rural areas in Nigeria (Bazuaye authorised by the Chief Medical Director. In
et al., 2009). Fewer studies had been carried out addition, written informed consent was obtained
with regards to the awareness of sickle cell status in from each respondent. All respondents were
the Local Communities in Ijumu, hence the purpose informed that the survey was voluntary; respondents
of this study.

were assured that confidentiality of responses would participants were students, 73 (22%) were unmarried
be maintained during and after data collection. and married 171(51%). Descriptive design was used
in this study in assessing and explaining the
Sampling Techniques perception and the awareness of participants toward
Probability sampling, using cluster random sampling their genotype and sickle status in Ijumu Local
was used within the communities in order to cover a Government area of Kogi state.
wider area. Fifty-two percent of the participants
were male and 48% were females. Statistical Analysis
Data compiled from the research work was analyzed
400 questionnaires were distributed within the local using a statistical package (SPSS 2014). Spearman
government communities (Iyara, Ekinrin-Adde, correlation and was used to establish significance
Egbeda, Iyamoye, Ogidi, Iffe and Ijumu) and relationship between variables; and graphical
respectively of which 335 (84%) questionnaires representation of the data was represented using
were returned. The study participants were further frequency, percentages and bar charts.
grouped into three groups; 91 (27%) of the
Results
Table 1: Participants knowledge about their Haemoglobinopathy status
Status Yes No Total Count Percentage (Yes)
%
Student 28 63 91 30.8
Unmarried 14 59 73 23.3
Married 37 134 171 21.6
Total 79 256 335
Figure 1.0 Participant’s Haemoglobinopathy awareness by category
Figure 1.0 shows the participants knowledge about were in the married category, the degree of
their haemoglobinopathy status. Thirty-five percent unawareness among the unmarried remained a
of the respondent was categorized as students, 47% concern in this study, only 18% of the unmarried

category had knowledge about their Moreover, this did not affect their perception about
haemoglobinopathy status. their sickle status. Overall there was a significant
association between the participant’s knowledge of
Table 2.0 further confirmed that, the level of sickle cell status and the awareness about
awareness was higher among the married haemoglobinopathies (p<0.05).
participants compared to unmarried and the students.
Table 2.0: Awareness among subjects about their Haemoglobinopathy status

Status Yes No Total Count Percentage
(Yes)%
Student 41 50 91 45.0
Unmarried 40 33 73 54.8
Married 150 21 171 87.7
Total 231 104 335
More than half of the total participants in this study admitted that an electrophoretic pattern having an S
knew what haemoglobinopathies are and 40.3% carrier gene can cause sickle cell disease (Table 3).
TABLE 3.0: Awareness of of Sickle Cell Anaemia as Hereditary Disease

Status Frequency Percent Cumulative Percent
I don't know 200 59.7 59.7
Hereditary 135 40.3 100
Total 335 100
Table 4.0: Knowledge of Partner’s Haemoglobinopathy status

Status Yes No Total count Percentage
Yes (%)
Unmarried 15 58 73 20.5
Married 50 121 171 29.2
Total 65 179 244
Table 4.0 shows that 20.5% of (Unmarried) enlightened about sickle cell disease from this small
participants knew the haemoglobinopathy status of study with a response of 29.2% that knew partner’s
their prospective partners. This open up the further haemoglobinopathy status. There was a weak
exploration of health promotion and counseling association between marriage status and knowledge
before and after marriages. It was also identified that of their partners haemoglobinopathy status in this
the married participants were also poorly study (p >0.05).
Table 5: Availability of Equipped Laboratory Facilities

Status Frequency Percent Cumulative Percent
Yes 153 45.7 45.7
No 182 54.3 100
Total 335 100

Table 6: Provisions for Screening for Sickle status

Response Frequency Percent Cumulative Percent
Yes 132 39.4 39.4
No 203 60.6 100
Total 335 100
Four-five percent of participants in this study were the disease persists among Nigerians. We assumed
asked about access to a health facility within the that married respondents in this study tend to have
Local area but only 39.4% were aware of diagnostic gained more insight about sickle cell diseases,
services within the local communities. probably after giving birth to a child whose
haemoglobinopathy status needed to be tested due to
Discussion sickle crisis. There is need to increase pre-marital
In this study, it was observed that the degree of screening awareness and compliance must be
awareness among the student participants was verified. A previous report (Chandnani et al., 2013)
considerably lower than expected; only of 45% the indicated that in Nigeria, there is no universal
total population of the student in secondary schools newborn screening program and no uniform
are aware of haemoglobinopathy screening and what premarital testing for sickle cell disease, which
it’s used for. Married people have an awareness of results in children with sickle cell disease being
87.7% and unmarried 54.8% of (73). But on the identified during illness. This trend need to be
contrary, the few students that were aware are those addressed if this goal must be attained. Increasing
with knowledge of their haemoglobinopathy status the proportion of individuals who are aware of their
30.8%. This may probably be due to health haemoglobinopathy status is a stated priority of the
promotion in few secondary schools that made Healthy People 2020 objectives and the World
screening compulsory before admission into the Health Organization’s 2006 sickle cell resolution
school. Only 21.6% of the married knew their status (USDHHS 2013; WHO 2006). Current modeling
and 23.3% of unmarried. This study highlighted the projects a 50 % increase over present levels of
challenges of counseling in Ijumu Local annual SCA births in Nigeria by the year 2050 (Piel
Government in Kogi State as previously identified et al., 2013). Many of the participants who have
by the study of Abioye-Kuteyi et al. (2009) heard about haemoglobinopathy screening and
conducted among local government workers of Ile- sickle status have little knowledge about the cause
Ife, 46 (25.1%) of the 183 married respondents did of the sickle cell disease while 40.3% of the total
not know their spouse’s sickle cell status while 23 population believed it is a hereditary disease while
(26.1%) of the 88 respondents engaged to a marital majority don’t know.
partner (committed to a marital relationship) did not
know their partner’s sickle cell status. Screening and From this study, it could be deduced that the low
the study on the attitudes and awareness of youths in awareness of knowledge of the participants of sickle
the Yaba Development area also highlighted that status might be due to the lack of laboratory facility
55% of youths in the age group of 15–19 years old in their respective local government areas. Only
had no exposure to SCA premarital counseling and 45.7% of the total population (335) has a laboratory
this same group also scored lowest in SCA facility and only 39.4% of these laboratory facilities
knowledge and had the highest rate of negative have the provision for haemoglobinopathy
attitudes towards SCA (Oludare and Ogili, 2013). screening.
Among the subjects, 70.8% (171) of the married There was an association between attitude and
couples when asked about the status of their partners knowledge of haemoglobinopathy screening and
were unaware or not confident to talk about it. The sickle status. Even though the majority were aware
premarital group also had poor knowledge, only about haemoglobinopathy screening, only a small
(20.5%) of them knew the status of their partners as proportion of subjects had good knowledge of SCD.

About a quarter of the married respondents did not counseling in Lagos Nigeria. It’s advocacy on
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Original Research
SJMLS-2(1)-2017-022
The Effect of Fermented Cyperus Esculentus Supplement on
Erythrocytes and Leucocytes Indices in Streptozotocin-Induced
Diabetic Wistar Rats
Tanko, Y. * 1, Gidado, N.M. 1, Abdulrazak, A. 2, Mohammed, K.A. 2
Department of Human Physiology, Ahmadu Bello University, Zaria, Nigeria 1, Department of Human
Physiology, Kaduna State University, Nigeria 2.
Corresponding author*: yusuftanko@abu.edu.ng /+234-803-705-4274
Abstract prevalence of diabetes in Africa (Padoa, 2011). In

This study investigated the effect of fermented Nigeria, the incidence rate in children ranges from
Cyperus esculentus on erythrocyte and leucocytes
1.6/1000 in Port Harcourt, Southern Nigeria (Opera,
indices in streptozotocin-induced diabetic Wistar
2008) and 3.1/1000 in Kano, North-West Nigeria
Rats. Diabetes was induced by streptozotocin
(Adeleke, 2010). In south-East Nigeria, a hospital
(4.5 mg/100 g b.w., i.p.). The Animals were grouped
into six groups of five animals per group. Group 1 is prevalence rate of 0.1/1000 was reported by Ibekwe
the normoglycaemic control group, Group 2 served (2011), while a community prevalence of 0.25–
as the diabetic control, Group 3 were administered 2 0.46/1000 was reported by Afoke (1992).
mg/kg glibenclamide, Group 4, 5 and 6 were fed for Management of this disorder involves changes in
4 weeks with 12.5, 25 and 50 % fermented lifestyle and the use of oral anti-diabetics (Quaseem
supplement of Cyperus esculentus respectively. The et al., 2012) which has both short-term and long-
results showed a significant increase (p<0.05) in the term implications, considering the increasing
packed cell volume (PCV), haemoglobin (Hb) and number of new cases. Therefore, novel therapeutic
red blood cell (RBC), mean corpuscular
options have to be considered, including the use of
haemoglobin concentration (MCHC), mean
nutritional supplements as alternative or
corpuscular volume (MCV) and a decrease in the
platelet count, white blood cell count, neutrophil, complementary agents which may improve the
lymphocyte and neutrophil lymphocyte ratio when quality of life of the patient.
compared with the diabetic untreated control group.
The results of this study suggest that the fermented Cyperus esculentus, also known as ‘Tiger nut’ in
cyperus esculentus supplement may have beneficial local parlance, is a plant of the family
effect on anaemia and immunity dependent Cyperaceae. Tiger nut has been widely used for
disorders. nutritional and medicinal purposes. Nutritionally,
100g has been shown to contain 386 kcal (1635 kJ)
Keywords: Cyperus esculentus, Fermentation.
of energy, of which 7% are proteins, 26% fats and
Streptozotocin, Erythrocytes, Leucocytes, Diabetes.
oils, 31% starch and 21% glucose. They contain an
Introduction appreciable level of fibre, about 26% of which 12%
Diabetes is a common community based disease are soluble and 14% are non-soluble (Akua et al.,
among Nigerians (Alebiosu et al., 2013 and 2014). Tiger nut also has appreciable amounts of
Alebiosu et al., 2009). Nigeria has the highest minerals such as iron, potassium, sodium,

magnesium, zinc, copper, manganese, molybdenum, St. Louis, MO, USA). Kits for blood glucose level
and phosphorus. Also, it is rich in vitamins such as determination was a digital glucometer (Accu-check
vitamin B1, vitamin E and vitamin C (Djomdi et al., Advantage, Boche Diagnostic, Company). All other
2013). The presence of vitamins such as vitamin B1, chemicals and drugs were obtained commercially
C, and E in tiger nut makes it important for and of analytical grade.
consumption as it helps the body to withstand stress,
to improve fertility in men and women, delay cell Induction of diabetes mellitus
aging, increase the elasticity of the skin, and The animals were fasted from feeds for 12 hours
removal of acne and wrinkles from the skin before the commencement of each experiment, but
(Bamishaiye and Bamishaiye, 2011). The aim of the were allowed water ad libitum. The rats were
study investigated the effect of fermented Cyperus injected with streptozotocin dissolved in citrate
esculentus supplement on erythrocyte and buffer pH 4.5 in a dose of 60mg/kg body weight
leucocytes indices in streptozotocin-induced intraperitoneal. Since Streptozotocin is capable of
diabetes in Wistar rats. producing fatal hypoglycemia as a result of massive
pancreatic release of insulin, the rats were treated
Materials and Methods with 20% glucose solution intraperitoneally after 6
Animals hours (Stanley et al., 2001). They were kept for the
A total of thirty (30) Wistar rats of both gender next 24 hours on 5% glucose solution bottles in their
weighing between 120-180 grams were procured at cages to prevent hypoglycaemia. After a period of
the Department of Human Physiology animal house, three days the rats with a blood glucose levels
Ahmadu Bello University Zaria. The animals were greater than 180mg/dl were considered diabetic and
kept in an aerated laboratory cage in the animal used for this research work.
house of the Human Physiology department of the
Ahmadu Bello University. They were allowed EXPERIMENTAL DESIGN
access to food and water ad libitum. The study was After the induction of diabetes mellitus in the Wistar
conducted in accordance with the guidelines of rats, the animals were randomly divided into
Ahmadu Bello University rules governing the use of experimental and control groups as follows:
laboratory animals as accepted internationally by Group 1: Normoglycaemic control – Administered
(National Institute of Health Guide for Care and Use 100% of the animal feed for four (4) weeks
of Laboratory Animals). Group 2: Diabetic control received distilled water
(5ml/kg)
Collection and preparation of fermented Cyperus Group 2: Diabetic received Glibenclamide 2mg/kg
esculentus nuts orally for four (4) weeks
Cyperus esculentus nuts was purchased from Group 4: Diabetic fed on 12.5% Cyperus esculentus
NAPRI, Ahmadu Bello University, Zaria and were supplementation feed for four (4) weeks
authenticated at the Herbarium Section in the Group 5: Diabetic fed on 25% Cyperus esculentus
Department of Biological Sciences, Ahmadu Bello supplementation feed for four (4) weeks
University (ABU), Zaria, Kaduna state, Nigeria. A Group 6: Diabetic fed on 50% Cyperus esculentus
voucher specimen was deposited at the herbarium supplementation feed for four (4) weeks.
for future reference. The nuts were washed and
soaked in a plastic container for forty-eight hours, Determination of blood glucose levels:
with the water unchanged (fixed fermentation) All blood samples were collected from the tail vein
(Uyoh et al.,2009). After forty-eight hours, the seeds of the rats on weekly basis for 4 weeks. Fasting
were drained, air dried and ground into fine paste. blood glucose levels were determined by using
glucose oxidase method expressed in the unit of
Chemicals/Drugs/Equipment mg/dL (Beach and Turner, 1958) using the Accu-
The chemicals, drugs and equipment used for this Chek Advantage digital glucometer, (Roche
study includes: Streptozotocin (Sigma Aldrich Inc. Diagnostic, Germany) and the results were

expressed in the unit of mg/dL (Rheney and Kirk, Determination of packed cell volume
2000). Non-EDTA anticoagulated capillary tubes were
filled with the blood collected in bottles containing
Collection and Preparation of Serum Samples for anticoagulant from the Wistar rats. About 15 mm of
Analysis the capillary tubes were left unfilled and the open
At the end of the treatment period, all animals were end of each of the tubes was carefully sealed with
subjected to light anesthesia by exposing them to flame from a microburner. The tubes were then
chloroform soaked in cotton wool placed in loaded into a microhaematocrit centrifuge
anesthetic box covered with lid. Blood samples of (Hawksley, England) and centrifuged at 1000 x g for
about 3ml were drawn from the heart of each 10 minutes. A haematocrit reader (Hawksley,
sacrificed animal from all groups by cardiac England) was used to read the PCV value of each
puncture. The samples were collected in Eppendrof tube (Schalm et al., 1975).
tubes and were allowed to clot. Thereafter, the
serum was separated by centrifugation, using Denley Determination of haemoglobin concentration
BS400 centrifuge (England) at 3000 g for 10 The haemoglobin (Hb) concentration was
minutes. The supernatant collected were used for the determined using Cyamethaemoglobin method of
analysis. Barker and Silverton (1985). Blood sample (20 µL)
was pipetted into a tube and diluted with 5 mL of
Determination of Haematological Parameters Drabkin’s fluid and was allowed to stand for 3
Erythrocyte and leucocyte counts were evaluated minutes and the absorbance of the mixture read
using a haemocytometer as described by Dacie and using a spectrophotometer (Beckman Coulter®,
Lewis (1991). The packed cell volume was Model BU20, Australia) at a wavelength of 540 nm
estimated by the microhaematocrit method as against the reagent blank. The haemoglobin
described by (Schalm et al., 1975), while (Hb) concentration was calculated using the formula:
concentration was evaluated using the Hb = T x C x D (g/dL)/A x 1000
Cyanmethaemoglobin method (Barker and
Silverton, 1985). Determination of total and differential leucocyte
counts
Determination of total red blood cell count Absolute and differential leucocyte counts were
Total red blood cell counts were determined by determined as described by Dacie and Lewis (1991).
haemocytometer method as described by Dacie and The absolute counts were determined using a
Lewis (1991). The tip of a clean and dry RBC haemocytometer. The tip of a clean and dry WBC
pipette was placed at the edge of a drop of blood. pipette was placed at the edge of a drop of blood.
Blood was then drawn to the mark 0.5, Hayem’s Blood was then drawn to the mark 0.5 and Turk’s
fluid to the mark 101, and the mixture mixed fluid to the mark 11 and the mixture was mixed
thoroughly for 3-4 minutes. After the blood, has thoroughly for 3-4 minutes. The first two drops of
been well mixed with the diluents, the tip of the fluid were discarded, after which the
pipette was carefully wiped and quickly placed by haemocytometer was charged with the diluted blood.
the edge of the cover slip at an angle 30◦ to the The cells were allowed to settle for 3-4 minutes and
horizontal with its tip just touching the edge of the the chamber placed under the microscope. For
cover slip. The diluted blood was allowed to flow by differential count, a drop of blood was placed on one
capillarity action evenly and slowly under the cover end of a glass slide (UNESCOPE®, England) and a
slip. The cells were allowed to settle down for 2-3 blood film was made using a spreader. It was then
minutes and the chamber carefully placed on the allowed to air-dry. Leishman stain was poured over
microscope. The cells were then counted under the the film to cover it for 2 minutes. Thereafter, an
desire magnification. equal number of drops of distilled water were added
to the stain without allowing it to spill over. The
diluted stain was allowed to remain on the slide for

4-6 minutes. The diluted stain was flushed–off in a leucocyte/platelet Unopette system. The dilution
gentle stream of water for 30 seconds and left on a was mixed well and incubated to permit lysis of the
rack for about a minute, with the last wash covering erythrocytes. Following the incubation period, the
them. The slides were drained and put in an inclined dilution was mounted on a haemacytometer. The
position against a support. The stained smear cells were allowed to settle and then counted in a
appears bluish pink. It was then mounted on a specific area of the haemacytometer chamber under
microscope, and the cells were counted under a the microscope. The number of platelets was
microscope using oil immersion at x 1000. calculated per µL (x 109/L) of blood.
Platelet count Statistical Analysis

Platelet (PLT) count was done using the Data obtained from each group were expressed as
haemocytometry method and the improved mean ± SEM. The data were statistically analyzed
Neubauer’s counting chamber (Uko et al., 2013). using (ANOVA) with Tukey’s post-hoc test to
Whole blood was diluted with a 1% ammonium compare the levels of significant between the control
oxalate solution. The isotonic balance of the diluent and experimental groups. All statistical analysis was
is such that all erythrocytes were lysed while the evaluated using SPSS version 17.0 software and
leucocytes, platelets, and reticulocytes remained Microsoft Excel (2007). The values of p ≤ 0.05 were
intact. The standard dilution for platelet counts is considered as significant.
1:100. This dilution was prepared using the
Table 1: Effects of Fermented Cyperus Esculentus Supplementation on Some Erythrocytes Indices in

Streptozotocin-Induced Diabetic Wistar Rats
Treatments RBC Hb PCV MCV MCH MCHC Platelets
12
(x10 /L) (g/dl) (%) (fl/cell) (ρg/cell) (g/dL) (x109/L)
7.43 15.48 51.33 69.96  31.15  617.20
Normaglycaemic 20.860.34a
0.24a
 0.27  0.58 1.47
a a a
0.20a 29.17a
9.74  31.92 60.66  29.54  815.40 
Diabetic untreated 5.26 0.31 18.540.34
0.24  0.64 0.67 0.32a 32.6
Glibenclamide 6.78  0.19 11.8  36.46 53.76  32.56  768.60
17.66  63a
2mg/kg a
0.32 a  0.10a 1.28a 0.53a 41.06a
12.5%fermented 6.40  0.19 12.2  35.02 54.84  33.74  721.00

19.040.55a
Cyperus esculentus a
0.28 a  0.40a 1.60a 0.59a 58.07a
25%fermented 6.58  0.16 12.48 42.60 64.56  32.28  669.40

18.940.42a
 0.35a  0.03a 0.54a 0.82a 75.90a
50%fermented 6.30  0.13 12.5  41.20 65.38  30.12 663.60 

19.7  0.57 a
0.40 a  0.07 1.57 a 1.01 a 8.90 a

Table 2: Effects of Fermented Cyperus esculentus Supplementation on Some Leucocytes Indices in

Streptozotocin-Induced Diabetic Wistar Rats
WBC Neutrophil Lymphocytes Neut/Lymp
Treatments
(x109/L) (x109/L) (x109/L) Ratio
Normaglycaemic 7.18  0.36a 0.77  0.20a 5.71 0.90a 0.14  0.01a
Diabetic untreated 14.78  2.33b 4.48  0.26 8.49  0.48 0.53  0.03
Glibenclamide 2 mg/kg 11.14  1.60a 2.47  0.39 a 7.05  0.63 a 0.36  0.05 a
12.5%fermented
12.86  1.25a 2.73  0.45 a 8.01  0.33 a 0.34  0.10 a
Cyperus esculentus
25%fermented
10.64  0.92a 2.11  0.48 a 7.81  0.31 a 0.28  0.05 a
Cyperus esculentus
50% fermented Cyperus

11.28  0.53 a 2.21  0.5 a 7.96  0.94 a 0.29  0.03 a
esculentus
Discussion complications, including nephropathy, retinopathy

In the result obtained, there were significant (P < and macrovascular disease. Similarly, a previous
0.05) reduction in the RBC, PCV, and Hb, in the study observed that the mean values of TRBC, Hb,
diabetic control when compared with the normal PCV and MCHC for the diabetic patients are lower
control group. The result agrees with the finding that than those of the control group, indicating the
anaemia is a common pathophysiology, associated presence of anaemia in the former group (Ruchi and
with diabetes mellitus (Akindele et al., 2012). Pradeep, 2012). Anaemia has been shown to be a
However, administration of fermented Cyperus risk factor for cardiovascular disease in diabetic
esculentus significantly (p < 0.05) attenuated the patients, particularly those with chronic kidney
anemic response engendered by STZ, when disorder. There is advocacy to monitor and manage
compared with the diabetic control group. This may the development of anaemia in patients with type-1
be partly due to its ability to improve the erythrocyte Diabetes mellitus may predate an abnormality in
membrane integrity by the mitigation of oxidative renal function. Anaemia may also be significant in
damage to the erythrocytes membranes. Fermented determining the outcome of heart failure and
Cyperus esculentus may suppress hemolysis through hypoxia-induced organ damage in diabetes. While
osmoregulation and biomembrane stabilization several factors contribute to the increased
(Takagi et al., 2011). It may be hypothesized that prevalence of anaemia in diabetes, the failure of the
fermented Cyperus esculentus improved the kidney to increase erythropoietin in response to
erythrocytic indices through these mechanisms. The falling haemoglobin appears to be the dominant
link between chronic diseases and anaemia is well factor. Oxidation of these proteins and
characterized (Weiss and Goodnough, 2005). The hyperglycaemia in diabetes mellitus causes an
occurrence of anaemia in DM has been reported due increase in the production of lipid peroxides that
to the increased non-enzymatic glycosylation of lead to haemolysis of RBC (Arun and Ramesh,
RBC membrane proteins, which correlates with 2002). The major pathological consequences of free-
hyperglycaemia (Oyedemi et al., 2011). Anaemia is radical induced membrane lipid peroxidation include
associated with an increased risk of diabetic increased membrane rigidity, decreased cellular

deformability, reduced erythrocyte survival, and neutrophil activation (Kim et al., 2006), and by the
lipid fluidity (Kolanjiappan et al., 2002). The modulation of immune function through the
decrease in MCH and MCHC values, observed after inhibition of the respiratory burst enzymes,
administration of STZ, is an indication of abnormal myeloperoxidase (Stapleton et al., 1998).
haemoglobin synthesis, failure of blood
osmoregulation, and plasma osmolarity (Stookey et The result obtained in this study showed that the
al., 2007). Platelet count was significantly (p < 0.05) higher in
diabetic control group when compared to normal
The result obtained in this study revealed that STZ- control group. In contrast, a significant (p < 0.05)
diabetic rats elicited a significant (p < 0.05 increase decrease was recorded in the Platelet count in the
in leucocyte count when compared to the normal treated group administered fermented Cyperus
control, and the apparent leucocytosis in the diabetic esculentus when compared with the diabetic
control was attributed to neutrophilia and a decrease untreated group. This may be due to the ability of
in the lymphocyte count. The result is in agreement fermented Cyperus esculentus supplementation
with the findings of Chinonye et al. (2014), that STZ protect the platelet from oxidative damage through
induces leucocytosis in experimental animal. the reduction of the formation of lipid peroxidation
Previous report indicates that diabetic foot ulcer and within the platelet. The result is in agreement with
associated amputations are common among previous reports, which suggest that platelet counts
diabetics, particularly those with high random blood are higher and contribute to vascular events in
sugars. Base-line levels of acute phase reactants patients with insulin resistance (Taniguchi et al.,
(white blood cell count, polymorphonuclear 2003). Previous report show that Platelet and Total
leucocyte count, platelet count, erythrocyte White Blood Cells count are higher in patients with
sedimentation rate (ESR), serum C-reactive protein Types 1 Diabetes mellitus than without the
(CRP) and albumin and decreased haemoglobin metabolic syndrome and that the rise is in a “dose-
levels were associated with foot ulcer-associated dependent” fashion. Increase in Platelet and Total
amputation risk (Dalla et al.,2006; Yesil et al., White Blood Cells count with increasing blood
2009). Administration of fermented Cyperus glucose in patients with Types 1 Diabetes mellitus
esculentus significantly decreases the TWBC when could be a result of a stress response. The White
compared to the diabetic control. Kozlov et al. blood cells count have been reported to correlate
(1995) reported in a previous study that diabetes in positively with platelet counts, which may suggest
mice was accompanied by moderate neutrophilic that a shared mechanism drives both the elevated
leukocytosis and prolonged circulation times of platelet and White blood cells count in patients with
neutrophils and monocytes, and a shortened this syndrome (Jesri et al., 2005). Clinically elevated
circulation time of lymphocytes, which increases the platelet counts are frequently seen in diabetics with
susceptibility to infection. Furthermore, the a long duration of disease. Previous report seems to
increased Neutrophil-lymphocyte ratio (NLR) suggest the possibility that elevated platelet count
observed in the diabetic control was an additional could be used as a prognostic indicator of future
confirmation that the leucocytosis recorded in this diabetic complications (Sterner et al., 1998). In
group was due to neutrophilia. It is known that NLR conclusion, the results showed that the use of the
provides an indication of the inflammatory status in fermented Cyper esculentus supplementation was
patient and it can be used for the prediction of the capable of stimulating blood forming cells, as a
outcome of disease (Proctor et al., 2012 and good for haemopoietic conditions.
Halazun et al., 2008). In addition, NLR may also be
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Original Research
SJMLS-2(1)-2017-023
Seroprevalence and Impact of Hepatitis B e Antigen on Hepatic
Transaminases and CD4+ T Lymphocyte Counts Among Treatment
Naïve HIV with HBV Co-infected Subjects in Sokoto, North Western
Nigeria
Bello Hali1 and Lilian Okwubenata Okonkwo 2
Department of Medical Microbiology and Parasitology, Faculty of Basic Medical Sciences, College of Health
Sciences, Usmanu Danfodiyo University Sokoto, Sokoto State, Nigeria 1, Immunology Unit, Department of
Medicine, Ahmadu Bello University Teaching Hospital Shika, Zaria, Kaduna State, Nigeria 2
Author for Correspondence: bbhali298@yahoo.com/+234 -803- 967- 7492
Abstract (14.3 %) for ALT levels; 3 (42.9 %) for AST levels

Hepatitis B virus infection is the major cause of (p= 0.647; 0.658 for ALT and AST respectively).
chronic liver diseases especially in sub-Saharan There was no significant difference in the
Africa and Asia. Hepatitis B e Antigen is a marker of prevalence of HBe Ag based on gender (p = 0.674).
HBV replication has immunomodulatory effect and Study participants aged ≥ 45 years had higher
has been implicated in chronic course of HBV prevalence of HBe Ag 1(20.0 %) compared to those
infection and it increases the risk of hepatocellular aged < 45 years 6(18.8 %), however the difference
carcinoma. A cross sectional study method was was not statistically significant (p = 0.673). The co-
adopted in which treatment naïve HIV infected infected study participants with severe
patients were tested for HBV infection and patients immunosuppression have the highest prevalence of
with HIV and HBV co-infection were further HBe Ag 5 (22.7 %) compared to non- severely
+
screened for HBeAg. The effects of HBeAg on CD4 immunosuppressed 2 (13.3 %), though the
T lymphocyte counts and hepatic transaminases difference did not reach statistical significance (p=
were assessed and the associations of HBe Ag with 0.677). We recommend that clinicians should
some socio-demographic variables were assessed. include HBe Ag assessment as a routine
One hundred and eighty HIV study subjects investigation in the management of HBV infected
participated in the study. The prevalence of HBe Ag patients. There is need to re-consider HBe Ag as a
among HIV and HBV co-infected subjects was marker of HBV replication and treatment criteria
7(18.9%). Majority were females 109 (60.6 %), while especially in limited resource countries where HBV
males constitute 71 (39.4 %). About 37 participants DNA estimation is not widely available and many
were positive for HBs Ag and therefore co-infected patients could not afford it. More researches about
+
with HBV infection. The mean CD4 T lymphocyte HBe Ag at molecular level are required so as to
counts were lower among HIV and HBV co-infected provide basis for immunotherapy targeting HBe Ag
patients who were positive for HBe Ag (130 ± 119) as it is implicated in the immunopathogenesis of
compared to those who were negative for HBe Ag hepatitis B virus infection.
(221 ± 212) (p < 0.335). The prevalence of elevated
ALT and AST levels were higher amongst the HIV Keywords: Hepatitis B e Antigen, Hepatic
+
and HBV co-infected patients who were negative for Transaminases, CD4 T Lymphocyte Counts, HIV,
HBe Ag, 9 (30%) for ALT levels; 13 (43.3 %) for AST HBV Sokoto, North Western Nigeria.
levels than in those who were positive for HBe Ag, 1

Lewin, 2007; Lederman, et al, 2004 and Jung and

Introduction Pape, 2002). The negative impact (such as loss of
Both Human Immunodeficiency Virus (HIV) anti-HBs and decreased clearance of HBe Ag) that
infection and Hepatitis B Virus (HBV) infection HIV infection has on the natural history of HBV
have similar routes of transmission, therefore their infection increases morbidity and mortality of
co-infection is common. African region has a high HBV- related liver diseases among HIV with HBV
burden of both HIV and HBV infections (UNAIDS, co-infection (Thio, 2009). This study therefore
2016 and O’Shea, 2010). The prevalence of HIV aimed at determining the prevalence of HBe Ag
infection and HBV infection in Nigeria are 3.4 % among HIV and HBV co-infected patients and the
and 13.6 % respectively (Musa et al., 2015 and effect of HBe Ag on CD4+ T lymphocyte counts
UNAIDS, 2015). and hepatic transaminases.
Hepatitis B virus primarily infects and multiplies in Materials and Methods

the liver. Detection of Hepatitis B e antigen This cross- sectional study included 180 HIV
(HBeAg) in individual infected with HBV implies treatment -naïve patients aged 18-60 years old
that the virus is actively multiplying in the patient’s attending the HIV clinic at Usmanu Danfodiyo
liver and this is accompanied with high HBV viral University Teaching Hospital (UDUTH) Sokoto and
load and elevated hepatic transaminases levels Specialist Hospital Sokoto. The subjects were
(O’Shea, 2010). Elevation of Alanine recruited between March, 2014 to October, 2015.
Aminotransferase (ALT) and Aspartate Patients who decline to offer consent, or who have
Aminotransferase (AST) indicates liver cells injury. been vaccinated against HBV infection were
Hepatitis B e antigen can be found in acute and excluded from the study.
chronic course of HBV infection and
seroconversion to HBe antibody indicates both Ethical approval for the research was obtained from
long-term clearance of HBV infection and low level the ethical committee of the UDUTH, and Ministry
of HBV viral load (CDC, 2016). Hepatitis B e of Health Sokoto respectively prior to the
antigen has immunomodulatory effect and it has commencement of the study. Confidentiality was
implicated in the development of chronic HBV assured to the study participants. Interviewer
infection and it increases the risk of hepatocellular administered questionnaire was used for the
carcinoma (O’Shea, 2010; Chang and Lewin, 2007 collection of some socio-demographic and other
and Liang and Ghany, 2002). relevant information about the study participants.
Blood samples from the subjects were analyzed for
Prior to the introduction of HBV viral load HBsAg, HBeAg, Alanine aminotransferase,
estimation, hepatitis B e antigen was used for the Aspartate aminotransferase and CD4+ T-lymphocyte
assessment of HBV replication and treatment counts.
criteria in patients with chronic HBV infection
(Liang and Ghany, 2002). The HBV DNA Patients were initially tested for HBV infection
estimation is expensive, requires special skill and using HBsAg ELISA Kit (Fortress Diagnostic, UK)
widely not available in resource limited countries employing Enzyme Linked Immunosorbent Assay
such as Nigeria, while HBeAg assessment among (ELISA) technique. Patients who were positive for
HBV infected patients which is not routinely done HBV infection (positive for HBsAg) were further
in some centers in Nigeria, does not require much screened for HBeAg using HBe Ag ELISA kit
skill and is not expensive compared to HBV viral (DRG International Inc, USA) employing ELISA
load estimation. technique. For the CD4+ T lymphocyte counts
estimation, Cyflow counter analyzer (PARTEC,
The CD4+ T lymphocytes which are paramount in Germany) was employed. Agappe Kit (Agappe
the defence against HBV infection are also targets Diagnostics, Switzerland) was used for the
in HIV infection (Catalfamo et al., 2011; Chang and estimation of Alanine Aminotransferase (ALT) and

Aspartate Aminotransferase (AST) levels and

normal ranges were up to 49 IU/L and 46 IU/L Results
respectively. The CD4+ T lymphocyte counts, ALT One hundred and eighty HIV study subjects
and AST levels were compared between HIV and participated in the study. Majority were females 109
HBV co-infected patients with and without HBe Ag. (60.6 %), while males constitute 71 (39.4 %). About
37 participants were positive for HBs Ag and
Statistical Analysis therefore co-infected with HBV infection. Of the 37
The data was analyzed using Statistical Package for HIV and HBV co-infected participants, 7 (18.9)
Social Sciences (SPSS Version 20). Chi-square test were positive for HBe Ag. The mean age (years) of
and Student’s t-test were applied for the test of the co-infected study participants was 32 ± 10
significance. Level of significance was set at p ≤ (Mean ± SD). Table 1 shows the prevalence of
0.05. HBeAg in HIV and HBV co-infected study subjects.
Table 1; Prevalence of HBe Ag in HIV and HBV co-infected study subjects

Variable HIV and HBV co-infected participants
N = 37
Age (years) Mean ± SD
32 ± 10
HBeAg N (%)
7(18.9)
HBe Ag; Hepatitis B e antigen, HIV; Human Immunodeficiency Virus, HBV; Hepatitis B Virus, SD; Standard
Deviation,
Mean CD4+ T lymphocyte counts, elevated ALT (30%) for ALT levels; 13 (43.3 %) for AST levels
and AST levels in HIV and HBV co-infected than in those who were positive for HBe Ag, 1 (14.3
patients with and without HBe Ag %) for ALT levels; 3 (42.9 %) for AST levels,
The mean CD4+ T lymphocyte counts were lower though the differences did not reach statistical
among HIV and HBV co-infected patients who were significance (p = 0.647; 0.658 for ALT and AST
positive for HBe Ag (130 ± 119) compared to those respectively). Table 2 shows the comparison of
who were negative for HBe Ag (221 ± 212) (p = mean CD4+ T lymphocyte counts and the prevalence
0.335). The prevalence of elevated ALT and AST of elevated ALT and AST levels in HIV and HBV
levels were higher amongst the HIV and HBV co- co-infected patients with and without HBeAg
infected patients who were negative for HBe Ag, 9

Table 2: Comparison of mean CD4+ T lymphocyte counts, prevalence of elevated ALT and AST levels
in HIV and HBV co-infected patients with and without HBe Ag
Variable HBe Ag p-value
Positive (N = 7) Negative (N = 30)

+
CD4 T lymphocyte counts (Mean ± 130 ± 119 221 ± 212 0.335
SD)
Elevated ALT levels

Yes 1(14.3) 9 (30.0) 0.647
No 6 (85.7) 21(70.0)
Elevated AST levels
Yes 3 (42.9) 13 (43.3) 0.658
No 4 (57.1) 17(56.7)
HBe Ag; Hepatitis B e antigen, ALT; Alanine Aminotranferase, AST; Aspartate Aminotransferase, SD;
Standard deviation
Prevalence of HBeAg based on gender, age (< 45 compared to those aged < 45 yrs 6(18.8 %), however
yrs and ≥ 45 yrs) and history of multiple sexual the difference was not statistically significant (p =
partners 0.673). Table 3 shows the comparison of HBeAg
The prevalence of HBe Ag was higher in male prevalence based on gender, age (< 45 years and ≥
5(23.8 %) study participants compared to females 2 45 years) and history of maintenance of multiple
(12.5 %) (p= 0.674). Study participants aged ≥ 45 sexual partners.
yrs had higher prevalence of HBe Ag 1(20.0 %)
Table 3: Comparison of HBeAg prevalence based on gender, age and history of maintenance multiple
sexual partners.
Variable HBe Ag p-value
Gender
Females (N =16) n (%) 2 (12.5) 14 (87.5) 0.674
Males (N = 21) n (%) 5 (23.8) 16 (76.2)
Age (Years)
<45 6 (18.8) 26 (81.2) 0.673
≥ 45 1 (20.0) 4 (80.0)
Multiple sexual partners
Yes (N =29) n (%) 6 (20.7) 23 (79.3) 0.521
No (N = 8) n (%) 1 (12.5) 7 (87.5)
<= Less than, ≥= Greater than or equal to, HBeAg= Hepatitis B e antigen,

Severe immunosuppression and HBe Ag immunosuppressed 2 (13.3 %), though the

positivity difference did not reach statistical significance (p=
The co-infected participants with severe 0.677). Table 4 shows the comparison of HBeAg
immunosuppression have the highest prevalence of positivity among HIV and HBV co-infected patients
HBeAg 5 (22.7 %) compared to non- severely with and without severe immunosuppression.
Table 4: Comparison of HBeAg positivity among HIV and HBV co-infected patients with and without
severe Immunosuppression
HIV and HBV co-infection (N=37) HBe Ag p- value

+
Severe immunosuppression (CD4 T lymphocytes < 5 (22.7) 17 (77.3) 0.677
200 cells/mm³), N = 22,
None severe immunosuppressed (CD4+ T 2 (13.3) 13 (86.7)

lymphocytes > 200 cells/mm³), N = 15
HIV= Human Immunodeficiency Virus, HBeAg= Hepatitis B e antigen, <= Less than, ≥= Greater than or
equal to
Discussion The mean CD4+ T lymphocyte counts was lower

In this present study, we observed a prevalence of among co-infected patients with HBe Ag than in co-
18.9 % of HBeAg among HIV and HBV co-infected infected patients without HBeAg, however the
patients. Our observed prevalence is lower difference was not statistically significant. This
compared to what was previously documented in finding is comparable with previous report
Nigeria (28 % and 34 %) (Iroezindu et al., 2013 and (Khamduang et al., 2012). Similarly, Anderson et al.
Idoko et al., 2009) respectively. Similarly, higher (2016) in their study among HIV subjects reported
values of HBe Ag (26.1 % and 63 %) were recorded that baseline CD4+ T cell counts were not affected
among HIV and HBV co-infected patients in by HBe Ag status. In contrast to the current study,
Thailand and in Gambia (Jobarteh et al., 2013 and Idoko et al. (2009), documented a significantly
Khamduang et al, 2012) respectively. However, the lower median CD+ T lymphocyte counts among HIV
value obtained in this current study was greater than and HBV co-infected patients who have HBeAg
what was documented (11.2 %) by Ruta et al. (2005) compared to co-infected patients who were negative
in Romania. The possible reason for the higher rate for HBeAg. The current study and previous studies
of HBe Ag in Thailand compared to the current (Anderson et al., 2016 and Khamduang et al., 2012)
study may be because HBV genotype C which is had smaller sample size of HIV and HBV co-
associated with late HBe Ag seroconversion is infected patients compared to the study done by
predominant in Asia (Kim et al., 2011) and this was Idoko et al., (2009) and this may probably explain
evident as Khamduang and Colleagues (2012) the variation in attaining statistical significant
reported that about 87 % of the HIV and HBV difference in the various studies. Hepatitis B e
infected subjects had HBV genotype C. Another antigen affects T lymphocytes and it is implicated in
possible reason for the lower HBeAg prevalence the apoptosis of some subset of CD4+ T
recorded in the current study may probably be due to lymphocytes (Chang and Lewin, 2007). These
the small sample size of the co-infected study immunomodulatory effects of HBe Ag may explain
participants. why the mean CD4+ T lymphocyte counts was lower
among HIV and HBV co-infected patients with HBe

Ag compared to co-infected patients who were contrary results with regards to association between
negative for HBe Ag. gender and HBeAg status (Ijoma et al, 2009 and
Chu et al, 1993). Further studies may provide
It is expected that co-infected patients with HBe Ag insight about these discrepancies. The current study
would have higher prevalence of elevated ALT and did not find significant difference in HBe Ag
AST levels compared to co-infected patients who prevalence between age 45 years and ≥ 45 years,
were negative for HBe Ag. However, the current though participants aged ≥ 45 years had higher non-
study recorded higher rates of elevated ALT (30.0 significant prevalence. However, Iroezindu et al.
%) and AST (43.3 %) levels among co-infected (2013) observed that age < 40 years was associated
patients who were negative for HBeAg than in co- with HBeAg seropositivity.
infected patients who were positive for HBeAg,
(14.3 %) for elevated ALT and (42.9 %) for elevated In this study, we observed a higher rate of HBeAg
AST levels, though the differences were not among co-infected patients with positive history of
statistically significant. This finding is comparable multiple sexual partners compared to co-infected
to observation made by Khamduang et al. (2012) participants with negative history of multiple sexual
with regard to ALT levels. Similarly, Anderson et partners, though it was not statistically significant.
al. (2016) observed that HBe Ag status do not have This result is similar to what was reported by
effect on ALT and AST levels at baseline. However, previously (Iroezindu et al.,2013).
Gilson et al. (1997) observed a significantly lower
ALT levels among HBV carriers who were negative In this current study, the prevalence of HBeAg
for HBeAg compared to HBV carriers who were observed was comparable between co-infected
positive for HBeAg, independent of HIV status. patients with and without severe
Risk of reactivation of HBV infection among HIV immunosuppression. Previous report (Saha et al.,
with HBV co-infection is increased due to loss of 2013) documented a higher prevalence among
anti-HBs (Thio, 2009). Patients with chronic HBV severely immunosuppressed subjects. Our finding is
infection may have acute exacerbation with however at variance with previous reports
markedly elevated ALT levels and this phenomenon (Iroezindu et al., 2013 and Ruta et al., 2005) who
is more frequent among patients who are negative observed significant differences. In severe
for HBeAg (Liang, 2009). This latter scenario may immunosuppression, the CD4+ T lymphocytes count
explain why higher rates of elevated transaminases is less than 200 cells/mm³ and this is defined as
levels occurred among HIV and HBV co-infected immunologically defined AIDS. This finding may
patients who were negative for HBeAg than in co- explain the role of CD4+ T lymphocytes in the
infected patients who were positive for HBe Ag in clearance of HBeAg.
the current study.
Conclusion
Male study participants had higher prevalence of In conclusion, this study demonstrates modest
HBeAg compared to females, however the frequency of HBeAg among HIV and HBV co-
difference was not statistically significant. Similarly, infected participants. Higher rates of HBeAg was
Iroezindu et al. (2013) in their study comprising of observed in males, severely immunosuppressed
HIV and HBV co-infected patients and HBV mono- participants, study participants aged ≥ 45 years old
infected patients did not observe any association and subjects with positive history of multiple sexual
between gender and HBeAg status. Smaller number partners. HIV and HBV Co-infected participants
of males in their study might have affected their with HBeAg tend to have lower mean CD4+ T
findings. However, in the current study, more than lymphocyte counts compared to co-infected
half of the co-infected participants were male participants who were negative for HBeAg.
subjects and no association between gender and
HBeAg prevalence was observed. Studies among
Hepatitis B virus infected study subjects reported

Recommendations Professionals. Available at: www.cdc.gov/hepatitis

We recommend that clinicians should include /hbv/hbvfaq.htm Accessed on 3
HBeAg assessment as a routine investigation in the March 2017
management of HBV infected patients. We also Chang, J.J. and Lewin, S.R. (2007).
recommend that the use of HBeAg as a marker of Immunopathogenesis of hepatitis B virus
HBV replication and treatment criteria be infection. Immunology and cell Biology; 85: 16-
reconsidered particularly in limited resource 23.
countries where HBV DNA estimation is not widely Chu, C.M., Sheen, I.S., Lin S.M. et al., (1993). Sex
available and many patients cannot afford it. More Difference in Chronic Hepatitis B
researches about HBeAg at molecular level are Virus Infection: Studies of Serum HBeAg and
required so as to provide basis for immunotherapy Alanine Aminotransferase Levels in 10,431
targeting HBeAg as it is implicated in the Asymptomatic Chinese HBsAg Carriers,
immunopathogenesis of hepatitis B virus infection. Clinical Infectious Diseases; 16 (5): 709-713
Gilson, R.J., Hawkins, A.E., Beecham, M.R., et al.,
Limitations of the study (1997). Interactions between HIV and hepatitis
The stage of the HBV infection was not determined. B virus in homosexual men; effects on the
Inability of this research to assess pre-core mutants natural history of infection. International
was also a limitation. Another limitation of this Journal of Acquired Immune Deficiency
study was small sample size of the co-infected study Syndrome Society; 11(5): 597-606.
participants. Disease conditions such as myocardial Idoko, J., Meloni, S., Muazu, M. et al., (2009).
infarction, acute haemolytic anaemia, skeletal Impact of Hepatitis B Virus infection on
muscle disorders and pancreatitis that may cause Human Immunuodeficiency Virus Response to
elevation of AST levels were not assessed in the Antiretroviral Therapy in Nigeria. Clinical
study participants. Infectious Diseases; 49(8): 1268-1273.
Ijoma, U., Nwokediuko, S., Onyenekwe, B. et al.,
Conflict of interest: None declared (2009). Low Prevalence of Hepatitis B ‘E’
Antigen in Asymptomatic Adult Subjects with
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Original Research
SJMLS-2(1)-2017-024
Lipid Profile as a Biomarker of Atherogenicity in Subfertile client with
Hyperprolactinemia: A North- Central Nigerian University Teaching
Hospital Experience.
AbdulAzeez, I.M.* 1, Biliaminu, S.A. 1,3, Okesina, A.B. 1, Olatinwo, A.W.O. 2,3, Omokanye, L.O. 2,3,
Adunmo, G.O. 4
Department of Chemical Pathology and Immunology 1, Department of Obstetrics and Gynaecology 2, Assisted
Reproductive Therapy Unit (UITH) 3 and Department of Medical Biochemistry, University of Ilorin, Ilorin,
Kwara State, Nigeria 4.
Author for Correspondence *: abdulazeezmusbau@yahoo.com/+234-703-162-1047
Abstract in hyperprolactinaemic subjects when compared

Hyperprolactinaemia is associated with with controls. In contrast, there was no significant
amenorrhoea and decreased estrogen concentration difference when mean values of artherogenic index
which may lead to the elevation in total cholesterol and Castelli II in hyperprolactinaemic subjects were
and low density lipoprotein cholesterol (LDL-C) and compared with those of controls. This study
decrease in high density lipoprotein cholesterol revealed an association between
(HDL-C). The aim of this present study was to hyperprolactinaemia and dyslipidaemia with higher
evaluate lipid profile as an artherogenic biomarker in atherogenicity than the controls. We concluded that
hyperprolactinaemic sub-set of subfertile individuals. dyslipidaemia is common in hyperprolactinaemia
This cross-sectional study was carried among and as such early lipid profile is advised as well as
clients with hyperprolactinaemia at the Assisted holistic interpretation of lipid profile as prompt
Reproductive Unit of University of Ilorin Teaching treatment may prevent cardiovascular events in
Hospital, Ilorin between January and June 2015. hyperprolactinaemic patients.
Serum fasting total cholesterol (TC), triglycerides
(TGs), high density lipoprotein cholesterol (HDL-C), Keywords: Biochemical, Atherogenicity,
and low-density lipoprotein cholesterol (LDL-C) Hyperprolactinaemia, Subfertile client, North-
levels were measured in 51 women with Central Nigerian.
hyperprolactinaemia who were non-pregnant and
not breastfeeding and 40 age-matched non- Introduction
pregnant and non-breastfeeding women of child
Subfertility generally describes any form of reduced
bearing age. Comparisons between serum hormonal
fertility with prolonged time of unwanted non-
profiles as well as lipids profiles as biomarkers of
artherogenic index were assessed. Women with
conception and have been reported to be associated
hyperprolactinaemia present with significantly lower with hyperprolactinaemia (Gnoth et al., 2005).
serum level of FSH, progesterone and oestradiol Hyperprolactinaemia is defined as circulating
than those of controls, while there was insignificant prolactin levels above normal range, which occurs in
elevation in mean LH. There was a significant conditions other than pregnancy and lactation, when
elevation in the levels of prolactin, testosterone, total physiological hyperprolactinaemia occurs
cholesterol, triglycerides, HDL-C, LDL-C, mean (Bernichein et al.,2010). It is one of the most
coronary heart disease risk ratio and Castelli ratio II common endocrine disorders of the hypothalamic-

pituitary ovarian axis affecting the reproductive and standards were measured against reagent blank
functions (Prabhakar and Davis, 2008). It is present using Jenway 6300 spectrophotometer at 505nm.
in as high as 9 to 17% in women with reproductive Atherogenic index (Log TG/HDL-C), Castelli risk
disorders (Biller et al., 1999). index I and II (T. Chol/HDL-c and LDL-C/HDL-C)
respectively. Coronary heart disease risk ratio was
Prolactin is defined as a pituitary-secreted calculated as described by Bhardwaj et al (2013).
polypeptide hormone which acts primarily to Other descriptive parameters and information were
stimulate lactation during pregnancy as well as post- extracted from their hospital folders. Ethical
delivery (Kars et al.,2010). Hyperprolactinaemia approval was gotten from the Ethical committee of
has been shown to be associated with abnormalities the hospital.
of carbohydrate and lipid metabolism as well as
obesity, the mechanism is not well known but Statistical analysis
prolactin may have a direct effect on adipose tissue Statistical analysis was done using Statistical
(Doknic et al.,2002 and Ben Jonathan et al., 2006). Package for Social Science (SPSS version 20.0).
It has been demonstrated that, prolactin increase Results were expressed as means ± SD. Paired
triglyceride (TG) levels by reducing the lipoprotein sample t-test was used to compare means of results
lipase activity in adipose tissue (Ling et al.,2003). where appropriate. A p-value ≥0.05 was considered
Hyperprolactinaemia is associated with significant.
amenorrhoea and decreased estrogen concentration
which may lead to the elevation in total cholesterol Results
and low density lipoprotein cholesterol (LDL-C) and This cross-sectional study was carried among clients
decrease in high density lipoprotein cholesterol with hyperprolactinaemia at the Assisted
(HDL-C) (Hesmati et al., 1987). The aim of our it Reproductive Unit of University of Ilorin Teaching
present study was to evaluate lipid profile as an Hospital, Ilorin between January and June 2015.
artherogenic biomarker in hyperprolactinaemic sub- Serum fasting total cholesterol (TC), triglycerides
set of subfertile clients. (TGs), high density lipoprotein cholesterol (HDL-
C), and low-density lipoprotein cholesterol (LDL-C)
Materials and Methods levels were measured in 51 women with
The study was a cross-sectional one performed hyperprolactinaemia who were non-pregnant and not
among subjects with hyperprolactinaemia at the breastfeeding and 40 age-matched non- pregnant
Assisted Reproductive Unit of University of Ilorin and non-breastfeeding women of child bearing age.
Teaching Hospital, Ilorin between January and June Comparisons between serum hormonal profiles as
2015. A total of 51 female clients with well as lipids profiles as biomarkers of artherogenic
hyperprolactinaemia constituting a subset of sub- index were assessed.
fertile patients attending the facility were recruited
for the study. The subjects were aged 22 and 45 There was no statistically significant difference
years, while 40 healthy age and gender- matched when the mean age and plasma level of LH in
non-pregnant women were monitored as control. hyperprolactinemic subjects were compared with
The serum hormonal profile (LH, FSH, prolactin, that of controls (Table1). There was a statistically
Progesterone, Estradiol, which was analyzed using significant elevation in mean level prolactin and
Accubind (USA) ELISA kits. Serum total testosterone levels in hyperprolactinemic subjects
cholesterol was estimated by cholesterol Oxidase when compared with controls. Plasma levels of
method (Flegg, 1973). HDL-c and LDL-c were also FSH, progesterone and estrogen were significantly
estimated by enzymatic method while triglycerides reduced in hyperprolactinemic subjects when
were estimated using glycerol-3 phosphate oxidase compared with controls.
method as described by Jacobs and Van Demark
(1960) using commercially prepared kit by Agappe Significant elevations were observed in the mean
Dignostics Ltd (India). The absorbance of samples values of total cholesterol, triglycerides, HDL-C and

LDL-C, in hyperprolactinaemic clients when hyperprolactinemic subjects when compared with

compared with controls (Table 2). controls. On the other hand, there was no significant
difference in mean atherogenic index and Castelli
There was a statistically significant elevation in the ratio I between the groups.
mean value in CHD-RR and Castelli ratio II in
Table 1: Comparing Mean Values of Fertility Profile in Hyperprolactinaemic Clients with the Controls.
Variables Subjects Control p-value
Mean Age (Years) 30.0± 5.0 26.6± 5.6 0.421

Mean FSH (mIU/ml) 5.5± 1.9 7.3± 7.6 0.000*
Mean LH (mIU/ml) 5.0± 1.9 4.9± 1.8 0.691
Mean Prolactin (ng/ml) 56.7± 35.8 14.3± 2.5 0.000*
Mean Progesterone (ng/ml) 1.9 ± 3.7 5.1± 5.4 0.000*
Mean Oestrogen (pg/ml) 54.4± 50.0 103.3± 42.4 0.000*
Mean Testosterone (ng/ml) 0.4±0.3 0.31± 0.07 0.000*
Table 2: Comparing Mean Values of Lipid Profile in Hyperprolactinaemic Clients to That of Controls.
Variables Subjects Control p-value
Mean T-C(mmo1/L) 4.1± 1.5 3.5± 0.5 0.000*

Mean Trig (mmo1/L) 1.3± 0.7 1.0± 0.2 0.000*
Mean HDL-C (mmo1/L) 1.6 ± 0.7 1.3± 0.3 0.001*
Mean LDL-C (mmo1/L) 1.5± 0.7 1.3± 0.2 0.000*
Table 3: Comparing Mean Values of Biomarkers of Atherogenicity in Hyperprolactinaemic Clients and

the Controls.
Variables Subjects control P-value
Mean CHD-RR 0.40± 0.10 0.36± 0.08 0.000*

Mean atherogenic index - 0.103± 0.162 -0.108± 0.072 0.152
Mean Castelli ratio I 2.66 ± 0.07 2.39± 0.53 0.202
Mean Castelli ratio II 0.73± 0.17 1.69± 0.44 0.000*
Discussion and impaired reproductive function (Berinder et al.,

Hyperprolactinaemia is the most common endocrine 2005). Metabolic abnormalities such as obesity,
disorder of the hypothalamic-pituitary axis (Doknic dyslipidaemia and insulin resistance, which was
et al.,2002). Hyperprolactinaemia has long been shown to be associated with hyperprolactinaemia,
associated with oligoamenorrhoea, galactorrhoea are mostly not given the utmost attention it deserves

as it has been shown that hyperprolactinaemia may Berinder, K., Nyström, T., Höybye, C., Hall, K. and
leads to weight gain in human studies (Shibli and Hulting, A. L (2011). Insulin sensitivity and
Schlechte, 2009; Doknic et al., 2002 and Delgrange lipid profile in prolactinoma patients before and
et al.,1999). after normalization of prolactin by dopamine
agonist therapy. Pituitary; 14(3):199-207.
Many studies have reported adverse lipid profile Berinder, K, Stackenäs, I., Akre, O., Hirschberg,
such as hypercholesterolemia, hypertriglyceridaemia A.L. and Hulting, A. L (2005).
while others reported no alteration in Hyperprolactinaemia in 271 women: up to three
hyperprolactinaemia (Berider et al.,2011; Serri et decades of clinical follow-up. Clinical
al.,2006 and Yavuz et al., 2003). In this study, Endocrinology; 63 (4): 450-455.
elevated levels of total cholesterol, triglycerides and Bernichtein S., Touraine P. and Goffin V (2010).
low density lipoprotein cholesterol was observed. New concepts in prolactin biology. Journal of
The mechanism associating disorder of lipid Endocrinology; 206:1–11.
metabolism in hyperprolactinaemia is poorly Biller, B.M., Luciano A. et al (1999). Guidelines for
understood. Some reports associated this to a the diagnosis and treatment of
decrease in lipoprotein lipase activity in individuals hyperprolactinaemia. Journal of Reproductive
with elevated prolactin level. In addition, Medicine; 44:12.
hyperprolactinaemia leads to a reduction in estrogen Delgrange, E., Donckier, J. and Maiter. D. (1999).
levels by inhibiting the gonadotropin releasing Hyperprolactinaemia as a reversible cause of
hormone secretion, which may lead to an elevation weight gain in male patients? Clinical
in total and LDL-C as reported in this study Endocrinology; 50 (2): 271.
(Jellinger et al., 2012). Elevated coronary heart Doknic, M., Pekic, S., Zarkovic, M., Medic
disease risk ratio and LDL_C/HDL-C ratio as seen Stojanoska, M., Dieguez, C., Casanueva, F, and
in this study has been reported to be associated with Popovic, V (2002). Dopaminergic tone and
six times higher rate of atherosclerosis and other obesity: an insight from prolactinomas treated
coronary events (Jelllinger et al., 2012; Ramah et with bromocriptine. European Journal of
al., 2007 and Assman et al., 1998). In conclusion, Endocrinology; 147 (1): 77- 84.
our study revealed a possible association between Flegg. H. M. (1973). An investigation of the
hyperprolactinaemia and dyslipidaemia with higher determination of serum cholesterol by an
atherogenicity than the controls. enzymatic method. Annals of Clinical
Biochemistry; 10: 79-84.
Conclusion Gnoth., C., Godehardt, E., Friol, K. and Freundl, G.
We concluded that dyslipidaemia is common in (2005). Definition and prevalence of
hyperprolactinaemia and as such early lipid profile subfertility and infertility. European Journal of
monitoring is advised as well as holistic Human reproduction and Embryology; 20(5):
interpretation of lipid profile as prompt treatment 1144-1147.
may prevent cardiovascular events in Hesmati, H. M., Turpin, G. and de Gennes, J.L
hyperprolactinaemic patients. (1987). Chronic hyperprolactinaemia and
plasma lipids in women. Klin Wochenschr; 65
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Original Research
SJMLS-2(1)-2017-025
Some Haematological and Haemostatic Parameters Among Women
with Cervical Cancer in Sokoto, North Western Nigeria.
Ahmed, Y.2 Okwesili, A.* 1 Malami, I.1 Udoma, F. Erhabor, O1. Onuigwe, F1. Okwesili, O3. Buhari, H.1
Emenuga, V.4
Department of Haematology and Transfusion, Faculty of Medical Laboratory Science Usmanu Danfodiyo
University 1, Department of Obstetrics and Gynaecology Usmanu Danfodiyo University Teaching Hospital
Sokoto 2, Department of Surgery University of Nigeria Teaching Hospital Ituku - Ozalla Enugu 3, Department
of Medical Laboratory Science University of Nigeria, Enugu Campus 4.
Author for Correspondence *: okwesili4u@yahoo.com/ +234-703-788-5612
Abstract higher (25.82 ± 4.60 and 49.50 ± 5.49 seconds)

Worldwide, cervical cancer is both the fourth-most among cervical women compared to normal control
common cause of cancer and the fourth-most women (14.61 ± 1.90 and 33.82 ± 2.75 seconds)
common cause of death from cancer in women. In (p<0.05). Oncology patients are at a higher risk of
2012, an estimated 528,000 cases of cervical anaemia, thrombocytopaenia and deranged
cancer occurred, with 266,000 deaths. This is about haemostatic parameters (PT and APTT) that can
8% of the total cases and total deaths from cancer. predispose them to high risk of bleeding events.
The aim of this study was to investigate some There is need to routinely monitor the
haematological and haemostatic parameters among haematological and haemostatic parameters among
women with Cervical Cancer in Sokoto, North women with cervical cancer.
Western Nigeria. Some haematological and
haemostatics parameters of a total of twenty-two Keywords: Haematological, Haemostatic
(22) women with cervical cancer aged 40 to 60 Parameters, Women, Cervical Cancer, Sokoto,
years and a mean age of 50 ± 7.0 years, visiting the North Western Nigeria.
Gynaecology/Oncology unit of Usmanu Danfodiyo
University Teaching Hospital (UDTH) Sokoto, Introduction.
Nigeria were studied. A total of twenty-six (26)
Cervical cancer is cancer that begins in the cervix,
apparently healthy women aged 32-62 years with
the part of the womb (or uterus) that opens into the
mean age of 49 ± 9.0 years were monitored as
controls. The haematological parameters were
vagina. Cervical cancer is caused by a virus called
determined using manual methods. The mean PCV HPV (Human Papillomavirus). There are 2 main
and lymphocyte count was significantly lower among types of cervical cancer: squamous cell carcinoma
cervical cancer subjects compared to controls (2.45 and adenocarcinoma. About 80% to 90% of cervical
and 1.65) and (3.70 and 2.5) respectively (p <0.05). cancers are squamous cell carcinomas. These
There was no statistically significant difference cancers form from cells in the exocervix, and the
between the mean WBC, MCH, MCV, MCHC, cancer cells have features of squamous cells under
Platelet and RDW of cervical cancer subjects and the microscope. Most of the remaining types of
control subjects. The prevalence of anaemia
cervical cancers are adenocarcinomas.
(Hb<11g/dl) and thrombocytopaenia (platelet count
9 Adenocarcinomas are cancers that develop from
< 140 × 10 /l) was significantly higher among
cervical cancer subjects compared to controls
gland cells. Cervical adenocarcinoma develops from
(p<0.05). The mean PT and APTT was significantly the mucus-producing gland cells of the endocervix.

Cervical adenocarcinomas seem to have become and/or pathological factors. Haematological

more common in the last 20 to 30 years. Less components, which consist of red blood cells, white
common, cervical cancers have features of both blood cells or leucocytes, mean corpuscular volume,
squamous cell carcinomas and adenocarcinomas. mean corpuscular haemoglobin and mean
These are called adenosquamous carcinomas or corpuscular haemoglobin concentration are valuable
mixed carcinomas. in monitoring feed toxicity especially with feed
constituents that affect the blood as well as the
Thrombosis is a well-recognized and common health status of an individual (Oyawoye and
complication in patients with malignant disease and Ogunkunle, 2004). Red blood cells (erythrocytes)
can contribute significantly to the morbidity and serve as a carrier of haemoglobin, the major
mortality of this disease. Venous thromboembolism functions of the white blood cell and its differentials
is the most common complication of cancer and the are to fight infections, defend the body by
second most common cause of death in cancer phagocytosis against invasion by foreign organisms
patients (Abotchie et al., 2009; Aboyeji et al., 2006). and to produce or at least transport and distribute
Up to 60% of patients with cancer develop venous antibodies in immune response, and blood platelets
thromboembolism, depending on the type of cancer are implicated in blood clotting. Low platelet
and the treatment given (Adjorlolo-Johnson et al., concentration suggests that the process of clot-
2010 and Audu et al., 1999). formation (blood clotting) will be prolonged
resulting in excessive loss of blood in the case of
Haematological parameters are those parameters that injury. Previous report by Peters and colleagues
are related to the blood and blood forming organs (2011), indicated that Packed Cell Volume,
(Bamishaiye et al., 2009; Waugh et al., 2001). haemoglobin and mean corpuscular haemoglobin are
Blood act as a pathological reflector of the status of major indices for evaluating circulatory
exposed patient to infections and other conditions erythrocytes, and are significant in the diagnosis of
(Olafedehan et al., 2010). As reported by Isaac and anaemia and also serve as useful indices of the bone
colleagues (2013) animals with good blood marrow capacity to produce red blood cells as in
composition are likely to show good performance. mammals (Chineke et al., 2006 and Awodi et al.,
Laboratory tests on the blood are vital tools that help 2005).
detect any deviation from normal in the animal or
human body (Ogunbajo et al., 2013; Abdullahi, Materials and Methods
2009). The examination of blood gives the Study Site and Participating Hospital
opportunity to investigate the presence of several The study will be conducted in the
metabolites and other constituents in the body and it Gyenecology/Oncology unit of Usmanu Danfodiyo
plays a vital role in the physiological, nutrition and University Teaching Hospital Sokoto in
pathological status of an organism (Doyle, 2006 and collaboration with the Department of Haematology
Aderemi, 2004). According to Olafedehan and and Blood Transfusion Science of the Faculty of
colleagues (2010) examining blood for their Medical Laboratory Science of Usmanu Danfodiyo
constituents can provide important information for University Sokoto. The hospital is located in
the diagnosis and prognosis of diseases in patients. Wamakko Local Government Area within Sokoto
Blood constituents change in relation to the metropolis, and serves the host state Sokoto and
physiological conditions of health (Togun et al., neighbouring Kebbi and Zamfara states, including
2007). These changes are of value in assessing patients from Niger Republic. The teaching hospital
response of animals to various physiological is a 500- bed hospital and serves as a regional centre
situations (Khan and Zafar, 2005). According to for Neurosurgery and carries out specialized
Afolabi and colleagues (2010), changes in services such as dialysis, computerized tomography
haematological parameters are often used to (CAT scan), magnetic resonance imaging (MRI),
determine various status of the body and to radiotherapy among others. The hospital has a total
determine stresses due to environmental, nutritional of 700 health workers comprising of doctors, nurses,

midwives, laboratory scientists/ technicians, Eligibility Criteria

pharmacists radiologists/radiographers and Inclusion Criteria
physiotherapists. All consenting and legal adults (≥ 18 years) women
with cervical cancer who are not on anticoagulant
Sokoto is the capital city of Sokoto State. It lies therapy (warfarin and heparin) and ferrous sulphate
between latitude 1 3° 3’ 490 N, longitude 5° 1 4’ 890 presenting to Gynaecology/Oncology unit of
E and at an altitude of 272 m above sea level. It is UDUTH Sokoto were consecutively recruited into
located in the extreme North Western part of this study as subjects.
Nigeria, The state shares border with the Republic of
Niger to the North, Kebbi state to the West and Exclusion Criteria
Southeast and Zamfara to the east. Sokoto state has All non- consenting, non-legal adults (< 18 years)
an annual average temperature of 28.30C (82.90F). women with history of cervical cancer as well as
However, maximum day time temperatures are for those who are on anticoagulant therapy (warfarin
most of the year generally under 400C (104.00F). and heparin) and ferrous sulphate were excluded
The warmest months are February to April when from participation as subjects in this study.
day time temperatures can exceed 450C (113.00F).
The rainy season is from June to October during Sample Size Evaluation
which showers are a daily occurrence. There are two In a previous study carried out in UDUTH on the
major seasons, wet and dry which are distinct. prevalence of cervical cancer among female health
Sokoto metropolis is estimated to have a population workers involving 240 subjects, a prevalence of 5%
of 427,760 people (NPC/FGN, 2007) and by the was observed. The sample size for this study was
virtue of its origin, the indigenous inhabitant of the calculated based on the formula for the calculation
areas are the Hausa and Fulani other groups such as of sample size for a descriptive study in a population
Gobirawa, Zabarmawa, Kabawa, Adarawa, Arawa, less than 10,000 (Kirkwood, 1998), and 5%
Nupe, Yoruba, Ibos and others. prevalence is calculated from the formula thus;
Sample Size Evaluation
Occupation of the inhabitant include farming,
n=
trading, commerce, with a reasonable proportion of
the population working in private and public sectors Where, n= Sample size
(MOI, 2008). The Sokoto township is in dry Sahel z=standard normal deviation (1.96)
surrounded by sandy terrain and isolated hills. p= Prevalence which is 5%, 5/100=0.05
Rainfall starts late that is in June and ends early, in q= Complement of p (1-p)
September but may sometimes, it extends into d= Precision 5% (0.05)
October. The average annual rainfall is 550 mm with n = (1.96)2×0.05×(1-0.05) (0.05)2
peak in the month August. The highest temperatures n = 3.8416×0.05×0.95/0.0025
of 45°C during the hot season are experienced in the n = 3.8416×0.0475/0.0025
months of March and April. Harmattan, a dry cold n = 0.182476/0.0025
and dusty condition is experienced between the n = 73
months of November and February (Udo et al.,
1993). Modern Sokoto city is a major commerce Finite Population
centre in leather crafts and agricultural products N=42
(MOI, 2008). NF= ns/1+(n/N)
=73/1+(73/42)
Study Design =73/1+(1.74)
This present study was a descriptive case-control =73/2.74
study conducted among women with cervical cancer =26
at the Usmanu Danfodiyo University Teaching
Hospital, Sokoto.

Ethical Clearance and lymphocyte count was significantly lower

The Ethical clearance for the study was obtained among cervical cancer cases compared to controls
from the Ethics and Research committee of Usmanu subjects (2.45 and 1.65) and (3.7 and 2.5)
Danfodiyo University Teaching Hospital Sokoto. respectively with (p<0.05). There was no
statistically significant difference between the mean
Sample Collection WBC, MCV, MCHC, Platelet, and RDW of
Two millimeters (2 ml) of whole blood was cervical cancer cases and control subjects. The
collected into Ethylene diamine tetra-acetic acid prevalence of anaemia (Hb<11g/dl) and
(K3EDTA) bottle for full blood count (PCV, Total thrombocytopaenia (platelet count <140×109) was
leucocyte count, and differential white blood cell significantly higher among cervical cancer subjects
count) using the Mythic 22 (Orphee, Switzerland) 15(68.1%0 and 4(18.2%) compared to controls
five-part differential haematology analyzer at the subjects 1(3.8%) and 0(0%) respectively (p<0.05).
Haematology department of UDUTH Sokoto, The mean PT and APTT was significantly higher
Nigeria. Two milliliters of blood was collected into (25.8 ±4.60 and 49.50 ± 5.49 seconds) among
sodium citrate bottle for coagulation study (PT and cervical cancer women compared to normal control
PTTK). women (14.61 ± 1.90 and 33.82 ± 2.75 seconds).
There was a significant difference in all parameters
Results (PT and APTT) among the two groups (p<0.05).
Haematological parameters were compared between
cervical cancer cases and control. The mean PCV
Table 1: Age Distribution of Cervical Cancer Subject and Normal Controls

Age Group (Years) Subjects Control
30-40 4(18.2%) 7(29.2%)
41-50 7(31.8%) 7(29.2%)
51-60 10(45.5%) 8(33.3%)
61-70 1(4.5%) 2(8.3%)
Table1 show the age distribution of cervical cancer controls with mean ages of 50 ± 7 and 49 ± 9
subjects and normal control. A total of 48 women respectively. Majority of the cervical cancer were in
were studied, consisting of 22 of histological the 51- 60 years of age group 10(45.5%) compared
diagnosed cervical cancer patient and 26 normal to women in the other age groups.
Table 2: Mean Haematological Values among Subjects and Controls

Haematological Mean value of Mean value of t- value. p- value X2 - value
parameter Test Control.
PCV (%) 2.45 3.70 6.14 0.000 0.173
MCV (fl) 69.60 70.76 0.25 0.488 0.235
MCH (pg) 22.26 22.29 0.02 0.778 0.172
MCHC (g/dl) 31.69 30.33 -1.44 0.104 0.244
WBC (× 109) 10.815 5.94 1.55 0.05 0.235
RDW (%) 17.56 17.69 0.12 0.909 0.143
LYM(× 109/l) 1.65 2.50 2.91 0.001 0.187
PLT (× 109/l) 323.50 290.37 -0.99 0.372 0.113
Table 2 shows the mean haematological values Haematological parameters were compared between
among cervical cancer subjects and controls. cervical cancer cases and controls. The mean PCV

and lymphocyte count was significantly lower between the mean WBC, MCV, MCH, MCHC,
among cervical cancer compared to subjects (2.45 WBC, platelet and RDW of cervical cancer cases
and 1.65) and (3.70 and 2.5) respectively with and control subjects.
(p<0.005). There were no statistical differences
Table 3: Prevalence of Anaemia and Thrombocytopaenia among Cervical Cancer Subjects and Normal
Control
Haematological Number % Number of % p-value X2 -
abnormality Subjects
Anaemia 15 68.1 1 3.8 0.000 0.252
(Hb<11g/dl)
Thrombocytopaenia 4 18.2 0 0 0.6202 0.113
(platelet count <140
× 109/l)
Table 3: Shows the prevalence of anaemia and <140 × 109) was significantly higher among cervical
thrombocytopaenia among cervical cancer subjects cancer subject 15(68.1%) and 4(18.2%) compared to
and normal control. The prevalence of anaemia control subject 1(3.8 %) and 0(0%) respectively
(Hb<11g/dl) and thrombocytopaenia (platelet count (p<0.05).
Table 4: Mean values of PT and APTT of cervical cancer and normal control
Parameters Control Subjects t-value P-value
PT (seconds) 14.61 ±1.90 25.82 ± 4.60 -11.99 0.000
APTT (seconds) 33.82 ± 2.75 49.50 ± 5.49 -13.84 0.000
Table 4 shows the mean ± S.D of PT and APTT of cervical cancer women compared to normal control
cervical cancer subjects and normal controls. women (14.61 ± 1.90 and 33.82 ± 2.75 seconds).
The mean PT and APTT was significantly higher There was a significant difference in all parameters
(25.82 ± 4.60 and 49.50 ± 5.49 seconds) among (PT and APTT) among the two groups (p<0.05).
Table 5: Mean Value of PT and APTT among Cervical Cancer Subjects and Normal Control Group
Based on Age Group.
Age group (years) Parameters PT (s) APTT (s)
30-40 Control 14.43 ± 2.23 34.00 ± 3.46
Test 24.67 ± 6.38 49.50 ± 2.88
41-50 Control 15.86 ± 1.21 32.29 ± 1.18
Test 25.71 ± 3.99 46.71 ± 5.28
51-60 Control 13.50 ± 1.60 35.00 ±3.30
Test 27.57 ± 3.91 50.71 ±6.37
61-70 Control 14.00 ± 2.83 35.00 ± 1.41
Test 23.50 ± 3.54 55.00 ± 7.07
Table 5 shows the mean ± S.D of PT and APTT of PT and APTT values was found to be 24.67± 6.38
cervical cancer women according to their age and 49.50 ± 2.88 seconds respectively while the
groups. The mean PT and APTT value of cervical control was 14.43 ± 2.23 and 34.00 ± 3.46 seconds
cancer and normal control women was compared respectively. In the age 41-50 years, the mean PT
based on age. For the age group of 30-40 years, the and APTT for cervical cancer subject was 25,71 ±

3.99 and 46.71 ± 5.28 seconds compared to 15.86 ± (Hb<11g/dl) was significantly higher among
1.21 and 32.29 ± 1.18 seconds respectively for the cervical cancer subjects 1 5(68.1%) compared to
controls. In the 51-60 years’ age group, the mean PT control women 1(3.8%) respectively (p<0.05). The
and APTT of cervical cancer subjects was 27.51 ± prevalence of anaemia reported in this study higher
3.91 and 50.71 ± 6.37 seconds compared to 13.50 ± than that reported among Caucasians (Gascon and
1.60 and 35.00±3.30 seconds respectively for the Barret-Lee, 2006). This difference may be due to
normal controls. In the 61-70 years’ age group, the lower socioeconomic status and poor nutrition of the
mean PT and APTT values was 23.50 ± 3.54 and former. Anaemia seen in cervical cancer has the
55.00 ± 7.07 seconds compared to 14.00 ± 2.83 and characteristics of anaemia of chronic disorder
35.00 ± 1.14 seconds respectively for the normal associated with low PCV. Several factors may be
controls. responsible for the high prevalence of anaemia seen
among cervical cancer subjects in this study,
Discussion haemorrhage associate with iron deficiency,
Worldwide, cervical cancer is both the forth-most anorexia associated with cancers generally can also
common cause of cancer and the forth-most be associated with nutritional anaemia seen in these
common cause of death from cancer in in women. In cases, metastasis to the bone marrow from cervical
low-income countries, it is the most common cause cancer can be associated with suppression of
of cancer death and a major cause of mortality erythropoiesis and infection in fungating
among women. In this present study, we malignancies may be associated with red blood cell
investigated some haematological and haemostatic haemolysis(anaemia) and leucocytosis.
parameters among cervical cancer subject. Majority
of the cervical cancer subjects were in the 51-60 The role of haemoglobin levels in clinical outcomes
years of age group. None of the 22 patients was has been extensively examined in gynaecological
younger than 20 years, however, 77.3% of them malignancies, such as cervical, ovarian, and
were between 41-60 years, 18% were in the 30-40 endometrial cancer. In 1989, a retrospective study of
years’ age group and 4.5% were older than 61 years. 386 patients with advanced cervical carcinoma
Finding from this study is consistent with a previous treated with radiotherapy established that anaemic
report which indicated that 70% of cervical cancer patient had higher risk of treatment failures (Girinsk
in Nigeria was seen between 26-50 years with peak et al., 1989). Our finding is consistent with various
age range of 34-45 years (Gascon and Barret-Lee, studies which established an association between
2006). haemogloblin level and survival in cervical
carcinoma (Serkies et al., 2006; Fuso et al., 2005;
In this study, the mean PCV was significantly lower Winter et al 2004 and Obermair et al., 2003). A
among cervical cancer compared to control subjects retrospective review of 494 women with locally
(p <0.05). There was no statistically significant advanced cervical cancer treated with cisplatin and
difference between the mean (WBC, MCV, MCH, radiotherapy reported that low haemoglobin level in
MCHC, WBC, platelet and RDW of cervical cancer the last part of treatment were predictive of disease
cases and control participants. Our finding is reoccurrence and survival, whereas patient with a
consistent with a previous report which indicated haemoglobin level <10.0g/dl had a significantly
that red cell indices, mean WBC, MCV, MCH, lower PFS (Winter et al., 2004). Other cervical
MCHC, WBC, platelet and RDW of cervical cancer cancer studies have reported a relationship between
cases and control subjects. Our finding is consistent baseline haemoglobin level and better response to
with a previous report which indicated that red cell chemotherapy (Fuso et al., 2005), as well as longer
indices, mean MCV, MCH, and the mean RDW disease –free survival and OS in patient treated with
which is the coefficient of variation of red cell blood radiotherapy who had a baseline haemoglobin level
cells and anisocytosis was lower among cervical ≥ 12g/dl. Similar results have been described for
cancer patients compared to controls (Gascon and other solid malignancy, including ovarian (Gadducci
Barret-Lee, 2006). The prevalence of anaemia et al., 2003; Munstedt et al., 2003 and Obermair et

al., 2000) endometrial (Metindir et al., 2009; gynaecological and other types of cancers (Crasta et
Munstedt .,2004; Tamussino et al., 2001), al., 2010; Gerestein et al., 2009; Gungor et al.,
esophageal (Zenda et al., 2008; Vanlencia et al., 2009; Ayhan et al., 2006; Shimada et al., 2004 and
2006; Zhao et al., 2006; Rades et al., 2005 and Munstedt et al., 2003) esophageal carcinoma
Rades et al., 2005) and lung cancer (Xu et al., 2010; (Shimada et al., 2004) gastric cancer (Ikeda et al.,
Tomita et al., 2008; Aoe et al., 2005; Beradi et al., 2002) and lung cancer (Gonzale et al., 2010; Tomita
2005; Pradier et al., 2005; Langendijk et al., 2003) et al., 2008; Cox et al., 2000; Pedersen et al., 1996).
reporting that a low haemoglobin count is an In surgical resected NSCL, an increased pre-
indicator of poor prognosis. Finding from this study operative platelet count has consistently been
is a justification of the need for close attention to be associated statistically significant reduced survival
paid to anaemia before and during treatment, with when compared with patient without
the goal of maintaining adequate haemoglobin levels thrombocytosis. A high platelet count is an indicator
and, as a consequence ideally improving cancer of poor clinical outcome among cancer patients
outcome and quality of life. The mean WBC count (Borasio et al.,2008; Steele et al., 2005 and Herdon
and absolute Lymphocyte of cases were higher et al., 1998). Recent studies have examined the
among controls compared to cervical cancer prognostic role of the platelet count as an additional
subjects. This could be due to the fact that neoplasm risk factor that should be added to the IPPS (Patnaik
of all types is associated with neutrophilia. The et al., 2010) and the Dynamic International
natural killer cells are lymphocyte that are capable Prognostic Scoring System (DIPSS) (Gangat et al.,
of destroying tumour cells without prior 2011) for primary myelofibrosis (PMF). In these
sensitization. However, many tumours down- studies, researchers showed that platelet count <100
regulate expression of class 1. Major histo- × 109/l) is an independent prognostic factor of
compatibility complex (MHC) molecules as a way survival in PMF patient with a shorter median
of evading immunity. Lymphocyte count may survival when this factor was added to the above-
therefore elevated or depressed. mentioned prognostic scores. In the DIPSS study, a
platelet count <100 × 109/l was associated with
The mean platelet count of cases was also higher inferior survival in both the training set (n=428) and
among the cervical subjects compared to normal the test set (n=365) (Gangat et al., 2011).
controls. The prevalence of (platelet count <140
×109/l ) was significantly higher among cervical Finding from study indicates a significant difference
cancer subjects 4(18.2%) compared to control between the PT and APTT of cervical cancer
subjects 0(0%) respectively (p<0.05). Reactive subjects compared to control (p<0.05). The
thrombocytosis may be seen in cancer patients as a deficiency or depletion of coagulation factors
result of cancer induced anaemia. A negative characterised by a prolonged PT and APTT was
feedback effect on erythropoietic production in reported in a previous study (Ferrigno et al., 2001).
cases as a result of the anaemia could be for Similarly, Tas and Colleagues (2013) also reported a
responsible for the thrombocytosis. Erythropoietin tendency toward decreased survival for the patients
has a structural homology with thrombopoietin, with prolonged APTT among cancer patients. This
although the latter is considerably larger than the research work also shows that the mean PT and
former but roughly half of thrombopoietin at the N- APTT were higher among cervical cancer subjects
terminal region. (Hoffbrand and Lewis, 2001). compared to normal control women across all age
Determination of platelet count plays a significant bracket. Haemostatic measurement is vital in the
role in cancer management. The prognostic effective management of cancer patients. The
significance of the platelet count has been studied in history of a known association between coagulation
several malignancies, yielding important and cancer dates back to 1865, when Armand
information about clinical outcomes. Trousseau observed that patient who presented with
Thrombocytosis has been associated with idiopathic venous thromboembolism frequently had
unfavourable prognosis or advanced disease in an underlying occult cancer and vice versa

(Phlegmasia, 1865). Some coagulation factors that patients in the area. There is need for public
display a role in tumour progression have been enlightenment programme on prevention and need
reviewed (Sampson and Kakkar, 2002). The most for regular Pap smear screening among women in
frequent report on coagulant protein and cancer the area. The Nigerian government should
interactions include factor III (tissue factor; TF) implement evidence-based best practice by
(Rickles et al., 1992), TF-factor VIIa (Naschitz et providing universal access to HPV vaccination for
al., 1993; Zachaski et al., 1993), factor Xa young girls and women.
(Schmeidler et al., 1991), factor IIa (thrombin)
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Sokoto Journal of Medical Laboratory Science 2017; 2(1): 252

Original Research
SJMLS-2(1)-2017-026
Retraction Notice
Re: Ikpeama O.J., Nwoke, B.E.B., Uche, V. N. (2016). Pattern and Factors Affecting Weaning Practices
among Mothers attending Immunization Services at Comprehensive Healthcare Centre, Nwaorieubi, Mbaitoli
L.G.A, Imo State. Sokoto Journal of Medical Laboratory Science;1(2):91-110.
The Editor- in -Chief has received an application from the authors of the paper referenced above requesting
for the retraction of the article on the grounds of infringements of professional ethical codes, bogus claims of
authorship and unauthorized use of data.
In the light of the above, the editorial board has resolved that the said article be retracted. Any enquiries
concerning this retraction should be addressed to the Editor- in -Chief:
sokjmls@gmail.com or sokjmls@udusok.edu.ng

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Referencing a material published in a journal:

Erhabor, O., Adias, T.C. and Dallatu, M.K. (2016). HIV among women of African Descent in Abuja, Nigeria.
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Erhabor, O. (2016). Quality Management issues in Medical Laboratory Science practice.



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ISSN: 2536-7153 SJMLS

| SJMLS | Volume 2 | Number 1 | March 2017 |

SOKOTO JOURNAL OF MEDICAL

Article Processing Fee

SJMLS Volume 2, Number 1 March, 2017 | Page 1

Editorial Board Members

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SJMLS VOLUME 2, NUMBER 1 MARCH, 2017

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10. Original Article

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20. Original Article

Instructions to Authors 253 – 254

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Abstract active antibiotic against the various bacteria,

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Table 1: Prevalence of organisms causing Otitis media in children in Sokoto

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Figure 1: Percentage of frequency MAR index value ≥0.2 (%)

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Abstract associated with ABO blood group (p= 0.2913) and

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The main disease causing schistosome species are Study population

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Statistical analysis History of blood in urine (OR=16.319

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Table 2: Risk for urinary Schistosomiasis in children.

Use of nearby streams for

Presence of stream close

Table 3: Distribution of urinary Schistosomiasis in relation to clinical manifestation.

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proportion of glycosylated E2 is much lower in viral nucleocapsid is still to be determined as the

Figure 1: A generalized schematic representation envelope in which the E1 and E2 envelope

SJMLS Volume 2, Number 1 March, 2017 | Page 23

Entry factors Replication factors

N-ter C E1 E2 NS2 NS3 NS4B NS5A NS5B C-

host SPP, host SP, NS2/3, NS3/4A

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Conclusion Baba, T., Makino, R., Shibata, M., Harada, E.

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GBV-C/HIV-1 co-infection. Handa, A. and Brown, K.E. (2000). GB virus

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Research Design Sample size(n)= 3000/ (1+30000.050.05) = 3000/