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Neurocritical Care Status in Nigeria

By Currents Editor posted 01-03-2022 07:04

  
  1. Halima M. Salisu-Kabara CCRN, BNSC, MPA, PhD, FWACN. Practice Consultant, Kano, Nigeria
  2. Shuaibu Dambatta MBBS, FRCS. Northfield Specialist Hospital, Kano, Nigeria
  3. Dalhat Salahu, FWACS. Department of Anaesthesia, Bayero University Kano/Aminu Kano Teaching Hospital Kano, Nigeria
  4. Abdullahi S. Ibrahim, RN, CCRN, PGDPHEP, BNSc (in view) Intensive Care Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
  5. Folakemi Olufunbi Olufemi-Iseyemi, CCRN, BNSc Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria 

Introduction

Nigeria is a country on the coast of West Africa, bordered by BeninCameroonChad, and Niger, it shares maritime borders with Equatorial GuineaGhana, and São Tomé and Príncipe. With an area of 923,768 km² the country is almost four times the size of the UK or slightly more than twice the size of California. Nigeria's main rivers are the Niger and the Benue, the main tributary of the Niger. The country's highest point is Chappal Waddi (or Gangirwal) with 2,419 m (7,936 ft), located in the Adamawa mountains in the Gashaka-Gumti National Park, Taraba State, on the border with Cameroon [1].


Map of Nigeria

Nigeria’s Historical Background

Nigeria is made up of at least 250 ethnic groups, of which 3 are major groups comprising over 60% of the total population. Traditional medicine and healing constituted part of the micro- cultural evolution. In pre-explorers and pre-western trader's Nigeria, medical practices included herbalists, divine healers, soothsayers, midwives, spiritualists, bone-setters, mental health therapists and surgeons. Despite more than 150 years of introduction of western style medicine to Nigeria, traditional healing and medical practices remain a viable part of the complex health care system in Nigeria today [2].

Nigeria is currently made up of 36 states and over 500 local government areas. By the scheme proposed in the Fourth National Development plan, each Local Government Area would have a minimum of 7 Primary Health Care and 30 Health Centers with at least one Community Health Center at the apex of the health care services [3].

There are several health indicators used in assessing the health status of a nation. Nigeria’s unenviable ranking is the 187th nation in the world in terms of the health sector. The data that is available for assessing Nigeria's main Health Problems are very fragmented, unreliable and almost impossible to interpret. Trauma has taken a giant leap among the health care problems of Nigerians. It is believed to be the most common cause of death amongst Nigerians, particularly trauma arising from Road Traffic accidents [4].  

Neurological disorders account for more than 20% of the worldwide disease burden with Africa hosting the greater majority of people affected. Even more worrisome is the dearth of neurologists in the continent. The situation in Nigeria, the most populous black nation, is not different. Neurology has remained a relatively rare specialty in Nigeria leaving several patients under/misdiagnosed and therefore mismanaged. There is a paucity of data on the burden of neurological diseases. Currently, there are only about 70 neurosurgeons and about 80 registered neurologists serving a population of over 200 million people in Nigeria. The best neurosurgeon in Africa is a Nigerian, E. Latunde Odeku, who was the first African neurosurgeon trained in the United States [5].

Kano is the most populated state in Nigeria with a population totaling 9,383,682. The pattern of neurologic diseases in this area is not known. Stroke appeared to be the most common neurologic admission and the most common cause of neurologic and medical death in Kano, as observed in other regions of the country, where a little over one-fifths of stroke patients die. Central nervous system infections, mainly meningitis and tetanus, are the next most common cause of admission. The provision of a regional stroke unit, improvement of sanitary conditions of the home and environment, and the widespread use of immunizations against meningitis and tetanus have all gone a long way in reducing morbidity and mortality of stroke and neurologic infections [6].

Brief History of the Critical Care

The critically-ill patient poses a lot of management challenges to the managing physician, especially in low-income settings. This is truer in poverty-stricken developing countries where limited facilities in terms of beds, drugs and equipment are a common scenario. The first ICU in Nigeria was established at the University of Nigeria Teaching Hospital (UNTH), Enugu, in 1973, following the successful management of cardiac surgery patients there. Subsequently, other Federal Universities/tertiary care centres developed their own ICUs. Nigeria has 30 ICUs in all 6 geo-political zones, the majority of which (63.3%) are located in teaching hospitals. In Nigeria, the flagbearer of critical care is the Nigeria Society of Critical Care Nurses (NSCCN), formerly known as NANIN, a member of the World Federation of Critical Care Nurses (WFCCN), having been admitted in 2007 [7].

Current State of Neurological Care in Nigeria

Unfortunately, there are no dedicated neuro ICUs in the country’s public hospitals. However, there are a few private hospitals owned by Neurosurgeons and Stroke Physicians with Neuro-ICU facilities, an arrangement which is not unique to our country. Indeed, it is difficult managing head injuries properly in the public sector due to limited funding and resources. Public-Private Partnerships (PPPs) are one way to accelerate the development of specialized services like Neuro-Critical care, sponsoring ICP monitoring and even brain microdialysis. Recent funding has been provided by the Dangote Foundation and other corporate organizations like HealthShare.

Milestones Achieved

A global healthcare development company was founded in 2010 to provide free neurosurgical care for Nigerian patients and training for healthcare professionals. Regions Stroke and Neuroscience Hospital was conceived out of the necessity to provide high-quality care in Neurosciences in Nigeria, the most complete and comprehensive care for patients with neurological disorders such as stroke, epilepsy, Parkinson’s disease, memory disorders, Alzheimer’s disease, headaches, tremors, neuropathy, muscle weakness, back pain, brain tumors, and aneurysms. It utilizes the most advanced technology and innovative treatment options available, all of which are comparable to available treatments in Western countries.

As one example, an estimated 80% of Nigerians suffer from back pain, with causes that range from those involving muscles, ligaments or tendons, herniated discs, fractures or arthritis, congenital or traumatic deformities, or cancer. In cases that require surgery, such as those with herniated discs, modern techniques are available including minimally invasive techniques such as micro-discectomy [8].

The Aminu Kano Teaching Hospital in Kano has a 10-bed ICU that is well-equipped to cater for the critically ill (including neurocritical care patients). This includes state-of-the-art equipment, a complement of 3 neurosurgeons, 7 consultant anesthetists, a host of trainee doctors at various levels of training, and 21 critical care nurses trained and experienced in the multidisciplinary team approach in caring for critically ill patients. Patients with head injury, especially those with severe traumatic brain injury, are often ventilated for a period of time following intubation, and therefore comprise the vast majority of the neurocritical care patients we have seen in the ICU. Derived from our ICU registry, a total of 72 head injured patients were admitted into the unit over a 5-year period accounting for 15.3% of all ICU admissions. There was a total of 63 males (86%) and 9 females (14%) with a majority falling within the age range of 15 to 45 years (56%); road traffic accidents were the most common cause of injuries (74%). Timely diagnosis with neuroimaging was found to correlate with a positive outcome, as patients who had early CT/MRI were more likely to have operative interventions. There was a total mortality rate of 43.5%. Factors associated with poor outcomes were Glasgow Coma Scale < 5, post traumatic seizures, and multiple injuries (unpublished data). Most patients who underwent a craniotomy, often for the resection of a brain tumor, were ventilated in the post operative period to maintain optimal intracranial parameters.

Minister of Health, commissioning the New 10 Bedded ICU in Aminu Kano Teaching Hospital (AKTH), 2021

ICU at Lagos University Teaching Hospital (LUTH), Lagos, Nigeria

Lagos University Teaching Hospital (LUTH) - from 2016 to 2021, there were twenty head injured cases (9 died); fifteen SAH (9 died); sixteen excision of tumors (11); thirteen stroke cases (5 died). There is a special stroke center as well as another unit for trauma cases. The hospital is staffed by 3 Neurosurgeons, 3 Neurologists, 12 Anesthesiologists, 8 Critical Care Nurses and 22 other nurses. 

The Hon. Minister of Health arriving at the ICU at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria
Launching of the 10-bedded ICU at Aminu Kano Teaching Hospital, Kano, Nigeria
From the ICU launch at Aminu Kano Teaching Hospital, Kano, Nigeria

Challenges

Over half of the population of Nigeria lives below the poverty line on less than $1 a day, and therefore cannot afford the high cost of health care [9]. Also, a recent study by Akande had reported a poor referral system between the various tiers of health care, which probably speaks of the poor managerial functions of the health care delivery system [10].

Future Prospects

PPPs should be encouraged to promote novel drug development and to rapidly bring treatments to patients with brain disorders within Nigeria. Efforts to remove hurdles to research must also be supported at the governmental level, and there remains a need for a substantial increase in neurology services and training to facilitate implementing translational research. Long-term plans include the development of an Emergency Rapid Response and Referral System, training healthcare professionals in Emergency Neurological Life Support (ENLS) courses, and implementing early neurorehabilitation of these patients in the ICU.

Conclusion

Data from the Atlas Project [11] demonstrates that the available resources for neurological disorders within most countries remain insufficient. In addition, there are large inequalities across regions and different income levels, with extremely scanty resources in low-income countries. The neurologists practicing in a developing economy like Nigeria should expect to manage a significant proportion of non-neurological/general medical cases in the outpatient clinic, even in a tertiary level hospital facility. Nevertheless, the future is bright for neurocritical care in the country, as there is a lot of room for improvement. 

References

  1. https://www.nationsonline.org/oneworld/map/nigeria-political-map.htm. Accessed on 06/11/2021
  2. Scott-Emuakpor A. The evolution of health care systems in Nigeria: Which way forward in the twenty-first century. Niger Med J 2010; 51:53-65
  3. WHO 7th Report on World Health Situations, Vol. 2. African Regional Office, Brazzaville, 1987.
  4. Scott-Emuakpor A. The Evolution of Health Care Systems in Nigeria: Which Way Forward in the Twenty-First Century. Niger Med J 2010; 51:53-65. Available from: https://www.nigeriamedj.com/text.asp?2010/51/2/53/70997.
  5. Neuro Doctors in Nigeria. Blue Print Nigeria 2014. Accessible at: https://www.blueprint.ng/neuro-doctors-in-nigeria/ Accessed on June, 15th, 2021.
  6. Ibrahim, A., Owolabi, LF., Musa, BM., Aliyu, S., Rabiu, M., Yakasai, AM. Pattern of In-Patient Neurologic Review: An Experience from a Tertiary Hospital North-Western Nigeria. (2016). Annals of African Medicine, Vol. 15, Issue 2.
  7. Oguariri O, Kabara HS. Perspectives on Critical Care Nursing: Nigeria. World Federation Crit. Care Nursing. 2008; 6:2.
  8. Euracare Multi- Specialist Hospital Nigeria, Lagos. Nigeria. (Prof W. Sulaiman and RNZ Back and Spine Centre of Africa.) by Aisha Salahudeen, CNN. October, 4th 2019.
  9. Menizibeya Osain Welcome. The Nigerian health care system: Need for integrating adequate medical intelligence and surveillance systems. J Pharm Bio allied Sci. 2011 Oct-Dec; 3(4): 470 478. doi: 10.4103/0975-7406.90100. PMCID: PMC3249694.
  10. Akande TM, Monehin JO. Health management information system in private clinics in IIorin, Nigeria. Nig Med Pract. 2004; 46:102–7. [Google Scholar].
  11. Atlas: Country Resources for Neurological Disorders –2nd ed. Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO
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