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Mr Haruna Agwoi, the Coordinator, Primary Healthcare Centre of Kuje Area Council, FCT, has advised pregnant women in the area to avail themselves of regular antenatal care for the prevention of maternal deaths.
Agwoi gave the advice in an interview with the News Agency of Nigeria on Monday in Abuja, shortly after a sensitisation workshop on the importance of antenatal care for pregnant women in the area.
He said Primary Health Care (PHC) was designed to provide universal access to skilled pregnancy care for the prevention of maternal deaths, especially in rural communities.
According to him, antenatal care is an umbrella term used to describe medical care and procedures that are carried out for the pregnant women until delivery.
“Antenatal care is advocated as the cornerstone for reducing children’s deaths and improving maternal health for pregnant women.
“The care includes various screening tests, diagnostic procedures, prophylactic treatments, some of which are done routinely.
“It is aimed at detecting the already existing problems that can develop during pregnancy, affecting the pregnant woman and her unborn child.
“It is the healthcare that is rendered to the pregnant women throughout pregnancy until the child’s birth.
“Others are provided to the women based on identified problems and risk factors,” he said.
Agwoi also called for adequate sensitisation of antenatal care among pregnant women, saying that ‘very little is known of the use of PHC in rural areas’.
Besides, he revealed that the workshop was to sensitise and identify factors that lead pregnant women to use or not use existing primary health care facilities for antenatal and delivery care.
The Minister of Health, Dr Osagie Ehanire, has urged traditional rulers to strive to ensure Primary Health Care (PHC) service delivery and penetration of COVID-19 vaccination in the South-East. Ehanire made the appeal while inaugurating tthe South-East Traditional Leaders’ Committee (SETLC) on Primary Health Care (Services) Delivery in Enugu on Friday.
The event was organised by the Federal Ministry of Health in collaboration with National Primary Health Care Development Agency (NPHCDA) and Enugu State Primary Health Care Development Agency (ENS-PHCDA).
The minister noted that in order to push PHC services and COVID-19 vaccination forward, there was need to mobilise traditional rulers, who were very influential in their communities.
He said the ministry would rely on the traditional rulers’s power of advocacy and the respect they command among the people to push PHC services, which included COVID-19 vaccination, to the next and desirable level.
He said with the inauguration, the traditional rulers were made more relevant to issues of PHC services and should have input and oversight to ensure that centres in their communities functioned optimally.
Gov. Ifeanyi Ugwuanyi of Enugu State said that as gatekeepers of the communities, it was necessary to get them more involved in advocacy and ensuring that the PHC services were timely delivered to the people.
Ugwuanyi, represented by the state Commissioner for Health, Dr Ikechukwu Obi, said: “With the traditional rulers coming on board, we will soon achieve and even surpass our targets in various PHC services.
” He said that the state government over the years had strived in repositioning PHC services and structures, thus making the people to easily and affordably access PHC services at each ward in the state.
The Executive Director, NPHCDA, Dr Faisal Shuaib, also said that with the inauguration, the traditional rulers had been directly connected to the PHCs. He said: “there is no greater collaboration than working and going through traditional rulers to reach the communities.
“The people in the communities and localities listen more to them and the agency sincerely believes that the PHC services target will be better and faster realised through them.
” He called on the state and the entire south-east to do more in advocating increased COVID-19 vaccination and other PHC services.
The Chairman of the SETLC, Igwe Lawrence Agubuzu, said they had been part of the PHC before now but would this time personally ensure that all PHC services run successfully in the various communities.
Agubuzu, also the Chairman of Traditional Rulers’ Council in the state, said: “We are going to redouble our efforts by putting PHC services and COVID-19 vaccination advocacy at the front burner in our various communities.
“The traditional rulers in the South-East will also ensure that the PHC centres run optimally to the greater benefit of our subjects in our communities.
“We are going to use town criers, community and even our cabinet meetings to discuss PHC services and ensure that everyone in our communities is healthy and sound.
” The Executive Secretary of ENS-PHCDA, Dr George Ugwu, noted that the inauguration was a celebration of excellent PHC services Gov. Ugwuanyi had brought to the state through sound PHC policies and massive financial support.
Ugwu said that the inauguration would surely deepen PHC services and enlarge its coverage in the region as well as the building of more modern Type-3 PHC centres.
More than 792 million people in Africa live with mental health (MH) conditions.
Like many African countries, Zimbabwe does not have enough mental health specialists to support the population.
The Government of Zimbabwe recognizes mental health as a serious public health and development issue.
HM is recognized as a priority in the most recent National Health Strategy for Zimbabwe (2021-2025) and the current Ministry of Health and Child Care (MOHCC) HM Strategic Plan. In addition, there is still a significant discrepancy in the number of people with HM conditions who need treatment and those who receive this treatment, leading to large gaps in HM treatment.
To close the gap in HM treatment, the MoHCC is implementing the FRIENDZ program under the Zimbabwe Special Initiative for HM with the support of Friendship Bench (FB), UNICEF, WHO and ZimTTECH.
The FRIENDZ program aims to expand the assessment and management of priority mental, neurological and substance abuse disorders from the community to the primary and tertiary health care level in Zimbabwe.
Dr. Patience Mavunganidze, Acting Deputy Director of the MoHCC HM Department, emphasized the importance of the FRIENDZ programme, which will strengthen the MOHCC Primary Health Care (PHC) HM community and system in Zimbabwe.
“FRIENDZ will also strengthen referral pathways from the community level, through PHC and secondary and tertiary levels and down, as well as ensure oversight of support from higher to lower levels of care, creating a system of care of MH strengthened, accessible to the population.
” added Dr. Mavunganidze.
As part of the implementation of the FRIENDZ programme, MoHCC, with the support of UNICEF and WHO, trained 30 trainers of trainers (ToTs) from 10 different provinces between 2-5 August 2020.
The ToTs received training on support competency-based psychosocial, psychological treatments and foundational training.
Help skills using the WHO MH Action Gap (mhGAP).
The ToTs are expected to cascade the training across their various provinces with the support of FB and ZimTTECH.
Under the FRIENDZ programme, the friendship bank will expand problem-solving therapy (PST) services in Zimbabwe.
This will be done through training of lay health workers (village or community health workers) on common mental health problems, self-care and how to provide basic PST.
"We also hope to provide our FB and services to 34,480 women, men, girls and boys over the age of 16 who use our PST, which evidence has shown to significantly reduce symptoms of depression and anxiety," says FB, psychiatrist and program manager.
Clinician, Rukudzo Mwamuka.
“As Zim-TTECH, we will complement the work of FB and ensure that we train more health workers in 20 districts where FB is not present to ensure that we have more health workers providing HM in Zimbabwe,” says the director of Zim-TTECH, Rumbidzayi Dhiliwayo.
Strengthen MH governance and leadership, including smooth implementation of the FRIENDZ program.
Thanks to generous funding from USAID, MoHCC together with FB, WHO and ZimTTECH held awareness workshops with provincial leaders in Bulawayo and Gweru.
The provincial leadership awareness workshop held between August 22 and 26.
The main objective was to raise awareness among provincial leaders within the country's ten provinces, including discussion of integrating mhGAP into existing health programs.
Speaking on the sidelines during the Provincial Health Executive (PHE) awareness meeting in Gweru, Harare Provincial Medical Director Dr. Innocent Hove affirmed his support for implementing FRIENDZ in Harare.
“As we know, MH human resources are scarce and concentrated in major cities and hospitals, leaving 67.8% of Zimbabwe's total population living in rural areas, with limited access to care services.
of MH, the FRIENDZ program will go a long way to ensuring that underserved communities receive MH services,” said Dr. Hove. ”The FRIENDZ program seeks to empower Zimbabwe's mental health system with the capacity to provide basic mental health coverage to more than 3,000,000 women, men, boys and girls in three years.
These people receiving PST and mhGAP services will experience a reduction in symptoms and/or better daily functioning,” said Dr. Debra Machando, mental health specialist at WHO.
After the training, the ToTs are expected to pass on the training to other health cadres in Zimbabwe's ten provinces.
The goal is to ensure that knowledge is passed on to the PHC and to ensure that people in rural areas also receive quality mental health services.
The Nigeria Labour Congress (NLC), has commended all frontline health workers over the success recorded in routine immunisation.
It also urged Nigerians to get COVID-19 vaccine to protect themselves and the country.
The NLC President, Mr Ayuba Wabba, made the commendation on Thursday in Abuja, at the Sensitisation of Non-Health Stakeholders and Non-Professionals on the Importance of Immunisation and other Primary Health Care (PHC), Services.
The News Agency of Nigeria reports that the event was organised by the National Primary Health Care Development Agency (NPHCDA), to commemorate the 2022 African Vaccination Week (AVW).
Wabba, who stated the feat achieved in routine immunisation in the country, said it had reduced the prevalence of the virus.
He, therefore, called on all health workers and the leadership of NPHCDA not to leave any Nigerian behind in their efforts to eradicate the vaccine-preventable disease.
Wabba said, ”COVID-19 was not given chance to spread widely in the country, with their tireless efforts to ensure that Nigerians were protected from the scourge of the pandemic.
” He also called on Nigerians to make themselves and their loved ones available for immunisation against all vaccine-preventable diseases.
Wabba said that the collaboration of relevant stakeholders with the government would go a long way in strengthening the health system in the country.
In his opening remarks, the Director for Disease Control and Immunisation, NPHCDA, Dr Bassey Okposen, urged mothers to present their children for immunisation against preventable diseases and other health issues affecting children.
Okposen, who assured safety and efficacy of immunisation, said that the agency was poised to serve Nigerians on vaccine preventable diseases.
While debunking the myths of COVID-19 vaccines, he disclosed that about 63 million doses of the vaccines had been administered in the country.
He added that there was no record of death or any adverse illness such as madness as speculated by rumour mongers.
“If anyone asks you to pay for the vaccine, report to the authorities because it is free.
COVID-19 is not finished in Nigeria.
“It still kills as over 3000 people had died in the country from the virus.
“The Nigeria Centre for Disease Control (NCDC) had also recorded a spike in cases in the past four weeks; almost a whopping 400,000 cases weekly,” he disclosed.
He also reminded Nigerians that the RotaVirus vaccine was introduced and mothers should avail their children of immunisation across all PHCs in the country and it was free.
Okposen, who said the vaccine would prevent diarrhea, added that mothers and wards could take their children at six weeks, 10 weeks and 14 weeks.
A representative of UNICEF, Nigeria, Ms Carina Henriette Prakke, said that the first vaccine was made in 1979 for smallpox and it was not until 200 years later that smallpox was completely eradicated.
Prakke said that the first polio vaccine was discovered in 1952, but ”was eradicated in Nigeria 70 years later and this was achieved because Nigerians collaborated.
” She added that while the vaccine was good, it was not 100 per cent as the malaria vaccine provided a 50 per cent shield from the illness.
Prakke encouraged Nigerians to ask questions, find confidence in the vaccine and ensure that children were safe and prevented from diseases.
Mrs Chika Offor, the founder of the Vaccine Network for Disease Control (VNDC), said her organisation would continue to promote awareness and the benefits of vaccination services that saved lives and prevent disabilities.
Offor said vaccines for both old and young were available.
She said that there were Vaccine Schedules at all PHCs across the country and the nation could attain better immunisation coverage, ”if only Nigerians made themselves available.
” NAN reports that every year, World Health Organisation (WHO), marks AVW, in conjunction with World Immunisation Week. The week provides the opportunity to showcase the importance of vaccines and how they provide protection for both young and old, against more than 25 vaccine-preventable diseases.
This year’s theme is: “Long Life for All”, highlights the life-saving potential of vaccines for everyone, everywhere.
” Yet, in Africa, tens of millions of people were still missing out on some, or all, their scheduled immunisations against diseases that had long been eradicated by vaccines.
More than a year into the COVID-19 global vaccine rollout, Africa was benefiting from the speedy, efficient development of vaccines to curb the virus.
There are currently 10 COVID-19 vaccines available through the COVAX Facility, with more in the research and development pipeline.
Over 480 million COVID-19 vaccines had been administered in Africa to date, making it the biggest vaccine rollout in the history of the continent.
Only 18.7 per cent of the African population was fully vaccinated, lagging behind the global average of 58 per cent.
With the goal of achieving universal immunization, the Nigerian government through the National Primary Health Care Development Agency (NPHCDA), with the support of the World Health Organization (WHO) and its partners, the August 22, 2022, introduced the rotavirus vaccine in the Routine Immunization Program (RI).
The introduction of the vaccine to the RI program is recognition of the magnitude of rotavirus-related diarrheal disease, and the immunization program aims to prevent the death of more than 50,000 children from the disease each year.
With this, the vaccine that costs around N10,000 or more per dose in some health care centers across the country will be given free of charge to all babies at the age of 6, 10 and 14 weeks, along with other vaccines under the IR program.
Vaccine saves lives Speaking at the launch of the rotavirus vaccine in Nigeria's routine immunization schedule and the launch of the African Vaccination Week (AVW) 2022 in Abuja, the Minister of Health, represented by the Director of Health Public, Dr. Alex Okoh, said that the introduction of the life-saving rotavirus vaccine in the Expanded Program on Immunization (EPI) is important because it is expected to prevent more than 110,000 deaths in children under five in the next 10 years.
He said the Nigerian Government, with the support of our donors and partners, spent huge amounts of money to purchase RI vaccines because improving children's health remains a priority.
“We urge parents and caregivers to take advantage of the privilege of ensuring that their children are immunized against all vaccine-preventable diseases.
We also acknowledge the role of traditional and religious leaders, parents and caregivers, subnational Primary Health Care (PHC) leaders, and all health workers in 40,000 facilities for their tenacity, in ensuring that no Nigerian child is fall behind in access to powerful vaccines and other PHC services.
Additionally, NPHCDA Executive Director Dr. Faisal Shuaib thanked stakeholders, including WHO, for their support in getting Nigeria to include rotavirus in its RI program.
“We want to congratulate the stakeholders who have supported this event today.
With the launch of the rotavirus vaccine, all children will have the opportunity to receive the IR vaccine and we will be able to reduce infant mortality.
Like all other vaccines, it is free and safe and we urge parents to present their children to health facilities to receive their vaccinations,” he said.
Reduce out-of-pocket expenses Rotavirus is a virus that causes diarrhea and other intestinal symptoms.
It is highly contagious and is the most common cause of diarrhea in infants and young children worldwide.
Children are expected to receive all three doses of the vaccine orally, the first dose at six weeks, the second and third at 10 and 14 weeks, respectively.
In his welcoming remarks, the WHO country representative, Dr. Walter Kazadi Mulombo, congratulated the government on the introduction of the rotavirus vaccine in the EPI Program and said it provides an opportunity to reduce the number of children who die every day from diarrheal disease caused by rotavirus.
Dr. Mulombo said the public health impact of rotavirus vaccine introduction has been demonstrated in several countries and up to 50% of deaths from diarrheal diseases have been averted.
He said that the introduction is part of the comprehensive strategy to control diarrheal diseases with the expansion of preventive and treatment packages, as Nigeria is one of the 4 countries that harbor approximately half of the global burden of the disease.
“Immunization remains the most cost-effective public health intervention.
If we stop vaccination, deadly diseases will come back, and when people aren't vaccinated, infectious diseases that have become rare can quickly come back.
I want to commend the Nigerian Government's efforts to keep immunization high on the national agenda."
Let me assure you of WHO's continued commitment to providing technical support for the introduction of rotavirus vaccine into Nigeria's routine immunization program and indeed other health interventions, he said.
Relief for parents Meanwhile, Sarah Obiye Albert, a mother of three whose 6-week-old daughter benefited from the rotavirus vaccine launch, praised the government for the initiative.
She said this would reduce the money spent on immunization services by a parent, since she had to pay to get the vaccine for her two other children.
“We thank the government for making the vaccine available.
As a mother, I am grateful that it would reduce the money spent on a child's treatment or access to vaccination, she said.
Similarly, Kikelomo Lambo, a mother of two who attended the launch, said “today is a good day since the introduction of the vaccine in the RI schedule would reduce out-of-pocket spending on the vaccine.
“I paid N10,000 per dose for my children.
This meant that I paid N30,000 for all three doses.
This is high and many parents cannot afford it.
But now that it's free, many children will benefit, and this will reduce deaths or illnesses from rotavirus, she said.
Agency seeks fund’s partnership to implement SCALE 3.0 in Lagos Agency seeks fund’s partnership to implement SCALE 3.0 in Lagos L-R: Dr. Hamza Abubakar (Kaduna SPHCDA), Dr. Miapkewap Livinus (Plateau SPThe Lagos State Primary Health Care Development Agency (SPHCDA), is seeking the partnership of the Nigerian Solidarity Support Fund (NSSF), to expand its support of the COVID-19 vaccination.
SPHCDA said that the partnership was important as the country launches SCALES 3.0 through the National Primary Healthcare Development Agency (NPHCDA).
This is contained in a communiqué issued by NSSF at the end of its meeting with representatives of SPHCDA’s Forum of Chief Executive Officers (CEOs) in Lagos.
The communiqué, signed by Dr Fejiro Chinye-Nwoko, General , NSSF, was made available to the News Agency of Nigeria on Saturday in Lagos.
SCALES is an acronym for ‘Service delivery, Communication, Accountability, Logistics, Electronic reporting and Supportive supervision’ for the ongoing COVID-19 vaccination.
SCALES was introduced to rapidly ramp up COVID-19 vaccine coverage and reinvigorate routine immunisation uptake by expanding access to COVID-19 vaccines outside the health facility.
Dr Mohammed Adis, Executive Secretary, Nasarawa State PHCDA, expressed gratitude to NSSF for its previous and ongoing support towards the implementation of the COVID-19 vaccination programme in six states.
They are Adamawa, Edo, Imo, Katsina, Ogun and Nasarawa.
Adis, who is also the chairman of the forum said, ”with the aid of the funds received from NSSF, Nasarawa state moved from 32nd place at the last evaluation before December, 2021 to first position in June, 2022.” He said that NPHCDA had kicked off the SCALES 3.0 strategy in August to close the gaps identified during the implementation of SCALES 2.0, which NSSF was a part of.
According to him, the agency was soliciting additional support from the fund to make this a success as well.
He said, ”in addition to the six previously supported states, six more states were nominated to be considered for inclusion.
”They are Taraba State, Kaduna , Plateau,Cross River, Enugu State and Ondo.” The communiqué said that both partners agreed that with the benefit of key lessons from the implementation of SCALES 2.0, some gaps were identified during its implementations.
“Some logistics issues, but not limited to transportation, data entry in EMID platform and security were identified during the implementation of SCALES 2.0. ”And these need to be addressed with new strategies that has been put in place for SCALES 3.0. “The new phase also intends to address last-line visibility and would ensure that gaps at all levels, down to the PHCs, can be identified at the national level and attended to immediately.
“Additionally, the database used for COVID-19 vaccinations has been improved to capture performance; the performance of the teams involved, against their targets, to promote accountability,” the communiqué said.
On how NPHCDA was addressing the challenges posed by the pandemic, the agency said that all the states were making efforts to solve the problems with health service delivery and are at various stages of implementation.
The forum further said that they had recognized that technology was versatile and important, adding, ”we are making efforts to integrate it into the already existing systems.
“However, limited funding and supply of human resources for health remain their major blockers.
” On the presence of donor agencies and credible fund utilization, SPHCDA said that each state has an accountability framework that was developed by the World Bank along with NPHCDA.
It, however, stated that a software was being developed to enable all stakeholders to track and monitor expenditure.
It added, ”there is an Open Governance partnership in place that is funded and monitored by the Department for International Development (DFID), Bill & Melinda Gates Foundation (BMGF), and UNICEF.
“This gives all stakeholders access to all activities and programme areas and allows transparency.
” On grassroots engagement to bridge existing gaps, the forum said that stakeholder meetings were held regularly.
It said that the meetings involved community-based organizations (CBOs) and traditional rulers, adding that.
grassroots involvement was an integral part of the work that SPHCDA does.
The meeting considered several opportunities for expansion of NSSF’s interventions, especially in areas that do not necessarily relate to vaccination.
It was suggested that NSSF could consider looking into other issues like flooding and displacement or find a way to key into the insecurity situation and come up with interventions that will offset some of the effects.
Other areas of support such as research, programme design, and development of scientific papers were also highlighted for consideration.
NAN reports that NPHCDA is the agency that is concerned with the management and coordination of Primary Health Care (PHC) services in Nigeria.
To scale up COVID-19 vaccination efforts across the country, the NSSF signed an MOU with the NPHCDA in December.
2021. The programme is currently ongoing in six states across the country.
They are: Nasarawa, Imo, Edo, Katsina,, Adamawa and Ogun.
The Federal Government says that there are no short shelf doses of COVID-19 vaccine donations in the country.
The Executive Director, National Primary Health Care Development Agency, (NPHCDA), Dr Faisal Shuaib, said this in Abuja, at the official handover of about 2.6 million doses of Johnson Johnson COVID-19 vaccines.
Shuaib said that the vaccines were now promptly shipped and distributed through the COVAX and AVAT facilities to reduce the risk of expiration.
The News Agency of Nigeria reports that the vaccines were donated to Nigeria by the Canadian High Commissioner to Nigeria, Amb Jamie Christoff.
Following the expiration of one million doses of COVID-19 vaccines in Nigeria, the Presidential Steering Committee (PSC) on COVID-19, announced that the country would no longer accept vaccines with short shelf life.
The committee had said that such vaccines mounted undue pressure on health workers to administer them.
It also took the decision to destroy one million of such vaccines publicly, to assure Nigerians that there was no intention to use them.
Shuaib said that donors now recognised the need to give away vaccines before their expiration dates.
According to him, they have also created a pathway for prompt shipment and distribution through the COVAX and AVAT facilities to curb the risk of expiration.
“There is now better coordination, and the COVID-19 vaccines in the country are not expired nor have short shelf lives.
“The Federal Government, through the NPHCDA and other partners, has continued to ensure that the country received vaccines with a long expiration date,” he said.
He said that 62 million vaccine doses were available in the country at the moment, adding that 40 million more were being expected.
While commending the Government of Canada for providing “the much-needed support”, shuaib said that the donation was critical to helping the country ramp up its vaccination rollout process.
“Johnson & Johnson offers a single-dose opportunity for full vaccination, which means if you take one dose of the vaccine, you are regarded as a fully vaccinated person.
“However, we strongly recommend a booster dose after 2 months of taking the initial dose to strengthen your level of immunity against COVID-19. “A second dose of the vaccine serves as the booster dose,” he said.
According to him, “we are in a full campaign mode in which COVID-19 vaccines are ready-made available in the health facilities and other designated places.
“They are also brought by our vaccination teams to your doorsteps.
We are leveraging on our polio eradication experience to fight COVID-19. He expressed confidence that with the kind of support received from the Canadian Government, Nigeria would sooner than expected, be able to put COVID-19 behind.
On the SCALES 3.0 strategy, Shuaib said it offered opportunities for childhood vaccination and other Primary Health Care (PHC) services for Nigerians alongside the COVID-19 vaccination.
“Parents can take their eligible children for vaccination against polio, yellow fever, measles and other vaccine-preventable childhood diseases in the same locations where the adults receive COVID-19 vaccines.
“Our mobile teams are also in possession of all these vaccines when they visit your homes.
“Please welcome them and present yourselves and your eligible children for vaccination as may be applicable,” he said.
Christoff, while donating the vaccines, said it was his first assignment as an Ambassador to Nigeria.
The Ambassador recalled that the Canadian Government had earlier donated more than 800,000 doses of the AstraZeneca vaccine to Nigeria.
He said that the donation was in fulfilment of his country’s commitment to supporting developing countries in ramping up vaccination against the COVID-19 pandemic.
According to him, in 2020, the world was faced with the challenge to develop an effective vaccine.
“In 2021, the challenges evolved to the production and distribution of the vaccines.
Today in 2022, we need to put this vaccine within people’s reach,” he said.
Dr Eduardo Celades Blanco, UNICEF Nigeria Chief of Health, used the opportunity to call on eligible Nigerians who were yet to be vaccinated to do so.
“If we keep up with the vaccination, the likely scenario is that even though the virus continues to evolve, the severity of the disease will reduce over time.
“Immunity increases due to vaccination,” he said.
While appreciating the Canada for the donation, he said the gesture came at a time it was most needed.
He commended the recent survey on vaccination, stressing that in spite of the pandemic, the country was only one of the few globally that recorded improved Immunisation coverage.
The World Health Organisation (WHO) Representative to Nigeria, Dr Walter Kazadi Mulombo, also commended the country’s COVID-19 mass vaccination strategy.
Mulombo was represented by Dr Kofi Boateng, EPI Focal Point, Universal Health Coverage (UHC).
He said that other African countries were already looking up to Nigeria to learn how to roll out their vaccinations campaign.
NAN reports that as of Thursday, 40.7 million eligible persons have received the first dose of vaccines, while 28.6 million persons fully vaccinated.
This represents 25.6 per cent of the eligible population.
Meanwhile, 2.6 million fully vaccinated persons have received their booster doses.
Also, the SCALES 3.0 strategy enjoins the 36 states of the federation and the FCT to step up intensive actions to ensure that every eligible adult and child is vaccinated.
The Federal Government has also designed a performance-based incentive to improve the uptake of COVID-19 vaccines and other PHC services in the states and the communities.
The wife of Gov. Aminu Masari, of Katsina State, Hajiya Zakiyya Masari, has tasked nursing mothers in the state to ensure exclusive breastfeeding for their new born babies.
The governor’s wife made the statement on Thursday, in Mashi Local Government Area (LGA) during the launching of the ‘Stronger with Breast Milk Only” campaign, as part of the celebration of 2022 World Breastfeeding Week. The News Agency of Nigeria reports that the theme of this year’s celebration is, “Step up for Breastfeeding – Educate and Support.
” Zakiyya, represented by the permanent Secretary, Ministry for lands and survey, Hajiya Halima Othman, said the celebration came at the right time.
“We must understand the evidence-based recommendations for breastfeeding such as the fact that exclusive breastfeeding should be practised for the first 6 months of life.
”This should be followed by continued breastfeeding with appropriate complementary foods for up to 2 years or beyond.
“All mothers should be supported to initiate breastfeeding as soon as possible after birth, within the first hour after delivery and should receive practical support to enable them to establish breastfeeding.
“We must always remember that breastfeeding is not only important to the child, but also important to the mother, her family and the society at large,” she said.
The Katsina first lady urged that all community leaders and government sectors must include women in system transformations to ensure breastfeeding-friendly communities and workplaces respectively.
“For working women, this support comes in the form of maternity leaves and creches for their convenience.
“Even Islamically, mothers are expected to breastfeed their offsprings for two whole years.
I believe that every other religion across the state encourages the act of breastfeeding.
“Let us also frown at harmful breastfeeding practices, such as giving prelacteal feeds, expressing the first milk and pouring away, giving pre milk while able to breastfeed, giving traditional concoction and bottle feeding.
“And also mixed feeding in the first 6 months applying traditional herbs to breast as breast cleansing agent and maternal deprivation.
I hope my message appeals to the right audience as a God given opportunity, ” she said.
In his remarks, the Executive Secretary, Katsina State Primary Health Care Agency, Dr Shamsudeen Yahaya, said human breast milk is 80 per cent water.
“Especially the first milk sucked in each feed.
So, whenever the mother feels her baby is thirsty she can breastfeed.
”Babies do not need water before they are six months old, even in a hot climate.
“It is important to know evidence has shown that this feeding practice has been shown to significantly reduce mortality from two major childhood killer diseases, diarrhea and acute respiratory infections.
“Breastfed children have at least six times greater chance of survival in the early months than non-breastfed children,” Yahaya said.
Yahaya, who was represented by the Director of Primary Health Care (PHC) of the agency, Dr Nafisa Sani, said that exclusively breastfed children are 14 times less likely to die in the first six months than a non-breastfed child.
In his remarks, the District Head of Mashi and Iyan Katsina, Alhaji Kabir Aminu, advised the government to establish breast banks, if it is possible, so that orphaned children can be supported.
While saying newborn babies whose mothers die immediately after birth, hardly enjoy such exclusive breastfeeding, Aminu commended the UN Children’s Fund (UNICEF) and the state’s PHCA for organising the an event.
The Enugu Government, Nigeria Union of Local Government Employees (NULGE) and Nigeria Union of Teachers (NUT) have traded blame for the ongoing strike by workers in the local government councils of the state.
The News Agency of Nigeria reports that local government workers, including public primary school teachers and Primary Health Care (PHC) workers in the state on July 27, began a strike over alleged non-implementation of the N30, 000 minimum wage.
The strike was announced after a joint press conference by the leadership of the NUT and NULGE in the state.
The Chairman of NUT in the state, Chief Theophilus Nweke, told newsmen that the action which has crippled the affected sectors was due to government’s insincerity in the negotiation process.
Nweke said that the ongoing strike was the second time in two months public primary school teachers were embarking on such action over the same matter.
”The patience of the workers in those sectors is being overstretched as government has not made any concrete commitment to pay the minimum wage and its consequential adjournments.
”It is sad that pupils in the public primary schools could not participate in terminal examinations that could determine their promotions to the next class as the academic calendar was disrupted by the strike.
”The situation is more worrisome as the health centres in both urban and rural areas has remained closed.
“The government is aware of this strike but has not come up with any solution.
We are not happy being on strike.
So, government should look into it for industrial harmony,” he said.
He said that government had made an attempt to cajole them into suspending the strike by approving the payment of the minimum wage for workers in Grade Levels 1 to 6 in the affected sectors.
He, however, said that the labour unions would not fall for such bait as those that fell within such range were insignificant.
Nweke said that out of the 24, 000 workers in the local government system, including primary school teachers, those in Grade Levels I to VI were less than 2,000. Also speaking, the President of NULGE in the state, Mr Kenneth Ugwueze, said that it was unfair that the affected workers had been denied the minimum wage for 30 months.
Ugwueze said that some workers in the affected sectors still earned as low as N18, 000 monthly.
“This is the first time from the Old Anambra that we are having salary disparity and some categories of workers paid differently for over two years.
“You can imagine the impact it has on the rural populace.
Immunization activities have been put on hold,” he said.
Ugwueze said that the issue was no longer a question of meager financial allocations as the figures accruable to the various councils had improved tremendously.
“We had a meeting with the fourth committee constituted by government to resolve the matter but they requested that we suspend the strike before they open negotiations with us.
“However, it is on record that we have negotiated with previous committees for 30 months but nothing came out of it.
“We are no longer able to feed our families considering the hyper inflation in the country,” Ugwueze said.
When contacted, the Chairman of the Local Government Service Commission, Enugu State, Prof. Osy Okanya, said that government was serious about resolving the lingering strike.
”50 per cent of the problem has been settled.
”The state government planned to begin payment of the minimum wage in those sectors by August but for the actions of the union leaders.
“Government made it clear that implementation of the minimum wage in those sectors will start immediately for those in Grade Levels I to VI while we work out the consequential adjustments for Grade Levels 7 to 16,” he said.
Okanya said that government has convened a meeting with the labour leaders to work out the consequential adjustments without knowing that the unions had the intention of going on strike.
“There is willingness on the part of government to pay and we need some patience.
“While we are calling the unions back to the negotiating table, we are also making informal moves to find a middle ground in order to get it done quickly,” Okanya said.
Sone health experts have called for urgent revitalisation of Nigeria’s Primary Health Care (PHC) system to enable improved access to adequate medicare.
The experts made the call on Friday at the Nextier Health virtual dialogue on “Revitalising Nigeria’s PHC System“ in continuation of Nextier Universal Health Coverage (UHC) Series.
The News Agency of Nigeria reports that Nextier UHC Series is one of the flagship programmes of Nextier Health.
The series draw attention to contemporary health issues in Nigeria and globally through the views of health system experts and practitioners.
Akin Abayomi, the Lagos State Commissioner for Health, in his keynote address, highlighted the urgent need to address the challenges in the country’s PHC system.
Abayomi, who was represented by Dr Ibrahim Mustapha, Permanent Secretary, Lagos State PHC Board, said the major challenges facing PHC services included inadequate financing and human resources.
He said that other challenges were weak governance and accountability structures, poor data collection and transmission systems, limited access to medicines and essential infrastructure in PHC settings and supply chain.
Abayomi said that PHC system would require significant improvement to achieve UHC.
“All relevant stakeholders across the public and private sectors need to intensify their efforts and build sustainable partnerships to rejuvenate Nigeria’s PHC,” he said.
Chima Onoka, Head of Operations, Health Policy Research Group, said there was need for a clear delineation of roles and responsibilities of all tiers of government to ensure accountability processes.
Onoka, also a Community Physician, said each tiers of government should have financial autonomy to ensure it had the resources to perform its roles and responsibilities.
He said that local governments had not been able to effectively provide PHC services partly because they did not have direct control over their resources.
Onoka advised stakeholders at Federal and state government levels to focus on programme implementation and also provide financial and technical support for the health system leaders.
He, however, said that such health system leaders should be held accountable for expected responsibilities and resources.
Onoka said that the role of Civil Society Organisations (CSOs) and Development Partners in ensuring accountability emphasised the need for proper incentives to be considered in the design of accountability systems.
He called for a review of the scorecard for assessing performance in the Primary Healthcare System with best practices from other countries as bench mark.
Onoka recommended the need for stakeholders to present performance scorecards to the universities and similar independent institutions, that could assess the performance of PHC programmes and interventions objectively.
He said that for more objective review performance, development partners, stakeholders, CSOs and the public should also be allowed to review the reports and ask the right questions.
“This is in contrast to the current practice in which performance scorecards are presented to the board of the same organisation or public without giving room for effective engagement and unbiased assessment of PHC performance,” he said.
Onoka said that health system leaders and stakeholders needed to remove bureaucratic bottlenecks and create platforms that could enable them leverage available resources to achieve health system goals.
He called on state governments to create opportunities for stakeholders, including the private sector, to contribute to their health systems, particularly at the PHC level.
The expert said that the government must bridge the human resource gap by revising the training curriculum of health workers.
He said the government could also save money on capacity-building workshops for fresh graduates by incorporating the training content into the academic programmes curriculums.
Onoka said it was pertinent for government to build trust in the system as that would encourage more access to funds both domestically and externally.
He said there should be increased sustainable investments in the primary healthcare system with a focus on results.
onoka said there was also need to learn from past failures and best practices, and advised stakeholders to provide health system leaders with financial and technical resources they required to perform optimally.
Dr Sam Agbo, Senior Health Advisor, Foreign Commonwealth Development Office, Nigeria, said there was need for a clear definition of roles and responsibilities.
Agbo said National Primary Health Care Development Agency (NPHCDA) should consider acting more as a supervisory agency and focused less on programme implementation.
He said there was also need to improve coordination and synergy between State Ministries of Health and Primary HealthCare Development Agencies.
Agbo said Local Governments financial autonomy would empower them to take responsibility for organising PHC system while Federal and State governments provide the needed oversight and support.
He said professional organisations, Nigerian Medical Association (NMA), National Association of Nigerian Nurses and Midwives (NANAM), Association of Medical Laboratory Scientists of Nigeria (AMLSON) and Pharmaceutical Society of Nigeria PSN) should be encouraged to drive accountability.
He said the people, who were foremost stakeholders in a PHC system, must know their rights, demand them, and hold leaders accountable.
“The people are responsible for applying basic health education principles.
“Countries like China, India, Pakistan, Rwanda, Mali, and Niger with high-performing primary healthcare systems all have a people-centred and driven system.
”NGOs and CSOs should be people-oriented and advocate for interventions that mitigate disparities and protect vulnerable groups,” he said.
Agbo said that private sector should be given enabling environment to support the government to deliver on its mandate of ensuring that PHC system was built on the pillars of appropriateness, acceptability, accessibility, availability and affordability.
He said that the activities of development partners must be aligned and harmonised with government plans and people’s needs.
Agbo said that aligning programmes of development partners with on-ground priorities, remained a crucial strategy to ensure that donors’ catalytic investments made a difference and had far-reaching sustainable impact.
He said that before the Alma Ata declaration on PHC in 1978, Nigeria had a functional village healthcare system that provided services to the people at the community level.
Agbo said that in spite the present challenges being experienced, PHC system could be revitalised if all stakeholders were committed, worked tirelessly, acknowledged health as a human right and made it a political priority.
He described health as a business with a great return-on-investments and should be seen as such.
According to Dr Emmanuel Okpetu, Head, PHC, Kuje Area Council, instead of directly implementing programmes, national and state government agencies should provide technical support and oversight for LGAs. “This will bridge gaps at the PHC level with contextually appropriate solutions as that would help the three tiers of government to collaborate more effectively,” he said.
Okpetu said that a clear distinction between implementation and oversight roles of different stakeholders were important.
He said that most oversight functions expected from national and state agencies had been overlooked because they paid more attention to programme implementation at the expense of the oversight functions.
Okpetu said the number, distribution, and quality of human resources in PHC system were suboptimal, adding that task-shifting and sharing were great strategy to bridge human resource gaps.
He said that government should expand the scope of task shifting and sharing beyond maternal health services to include other conditions like non-communicable diseases.
Okpetu called on the government to make necessary policy changes that would make it easier for people to get trained to take up roles in the PHC system.
“The system is in dire need of human resources to provide clinical, laboratory and surveillance services,” he said.
Okpetu said that government should go beyond personnel recruitment and redistribution to ensure that appropriate incentives were in place to motivate PHC workforce and encourage personnel retention.
He said that community health extension workers were not motivated with ceilings which limit their career advancement.
“Incentives to be provided include career advancement opportunities and government-sponsored training with signed agreements for trained health workers to work for a specified time frame within the system or repay the cost of training,” he said.
Okpetu said there was need to allocate resources to carefully selected and clearly defined priorities.
He said that donors and development partners should avoid duplication of efforts and build trust with local stakeholders and focus on addressing real challenges within the health system based on priorities identified by the government.
Okpetu advised all tiers of government to consider innovative strategies to improve health system efficiency.
He added that governments could contract private sector to run non-performing PHC facilities and institute a pay-for-performance remuneration and financing system.
Dr Uju Onyes, a Health Policy and Financing expert, said there was need to reduce fragmentation in the health governance structure.
Onyes said the challenges of fragmentation was further complicated by absence of clear roles, responsibilities and accountability systems for PHC’s stakeholders and institutions.
She said that the deplorable state of PHC system and failed projects were due to poor accountability mechanisms in all tiers of government.
The expert said that stakeholders must work in synergy and deliver on their mandates as their collective action would strengthen the PHC system and make it resilient.
Onyes said although financial resources within national PHC system were inadequate, the inefficiency in resource utilisation was a challenge.
She said that governments and stakeholders should work towards revitalising the system as investments in PHC were cost-effective and would help Nigeria inch closer to UHC.


Face the Promise
Face the Promise is the sixteenth studio album by the American rock musician Bob Seger. The album was originally planned to be released in 2004, was delayed to 2005, and was officially released on September 12, 2006. It is his first studio album since It's a Mystery in 1995 and is Seger's first album not to be credited to "Bob Seger and the Silver Bullet Band" since Beautiful Loser in 1975. It took Seger six years to finish Face The Promise. The first single, "Wait For Me", was premiered in July 2006.


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Cute and Easy crochet by Nicki Trench
Type of item: Accessory
Yarn oddments and a sew-on brooch back
What was your inspiration?
Cute and easy crochet by Nicki Trench
What are you most proud of?
Finally producing a recognisable flower
What advice would you give someone starting this project?
Take your time and count the first row carefully

domain: hobby


Thank goodness for the Chinese. Together with India, China helped guarantee that this week’s G-8 meeting failed to reach any agreement on limiting carbon-dioxide emissions. Ironically, the actions of the People’s Republic should help America avoid going further down the road of over-regulation.
The refusal of China and India to go along with the carbon-dioxide limits should be the death knell for the Cap and Trade bill currently being considered by the Senate. The legislation is a pretty hard sell. Even advocates admit restrictions would only have a small effect — only a fraction of 1 degree Celsius, a virtually unnoticeable .07 degrees — on global temperatures by 2050.
Even if a worldwide agreement made sense, an agreement without China, India and other developing countries can be counterproductive. It could actually mean more, not less, carbon-dioxide emissions. With massive increases in energy costs for the United States, Europe and Japan, energy-intensive manufacturing will move to countries without limits. That would negate some of the carbon-dioxide reductions in countries with limits.
But the problem is worse than that. China, India and other less-developed countries generally use energy less efficiently. That means that any given product built in China or India results in even more carbon dioxide than if it were built in the West. If more energy-intensive manufacturing moves to China and India, the volume of shipping will grow to get those products to consumers around the world. Shipping consumes a great deal of fossil fuels.
Democrats in the House of Representatives partially understood these problems and tried to stop this flight of manufacturing with a provision that would tax imports from countries that don’t regulate their carbon emissions. The Obama administration correctly warned that this provision would lead to a trade war, which would completely dislocate the economy. This week, Senate Democrats, led by Sen. John F. Kerry of Massachusetts, announced that they would strip that House provision out of the Senate bill.
Without China and India, Cap and Trade will mean an even bigger loss of manufacturing jobs. Without these other countries on board for the regulation, Americans will suffer punitive energy taxes and still face a possible increase in carbon emissions. From every angle, Cap and Trade is a lose-lose proposition.


Obesity protects against death in severe bacterial infection
Obesity has always been looked at as a bad ailment one could have. But obesity is much more than hogging on food. It’s a broad range of diseases that includes many physiological, psychological and medical aspects. While obesity can be harmful and affects a person’s way of living and his/her mental health, a new finding suggests that obesity protects against death that occurs from severe bacterial infection. This study emphasizes that a higher BMI can be linked to higher survival rates in patients hospitalized for severe bacterial infections.
The study was conducted by scientists from Sahlgrenska Academy, University of Gothenburg, and Skaraborg Hospital in Skovde, and it was recently published in the journal PLOS ONE. The information was gathered before the COVID-19 epidemic. The population-based study included observations of all 2,196 persons receiving care at Skaraborg Hospital in Skovde for suspected serious bacterial illness over a nine-month period. The patients in this study cohort were monitored over time, both during and after their hospital stay. The findings demonstrate that a higher body mass index (BMI) was linked to a higher risk of survival in both the short and long term, at 28 days and one year after hospitalization, respectively. The disparities in survival rates were plain to see. Within a year, 26% of the normal-weight group had died. In groups with a higher BMI, the percentages were 9-17 percent. Similar results have previously been found in sporadic studies of small patient groups. The new findings support and validate the “obesity survival paradox,” which states that being overweight or obese protects against serious bacterial infections.
The pandemic has drawn attention to vulnerable patient groups, with overweight patients being particularly heavily hit. Perhaps COVID-19 and overweight patients’ experience and handling of treatment for patients with severe bacterial infections can be used to enhance the prognosis. What we don’t know is whether being overweight or can help a patient with a bacterial illness or whether obesity protects against death, or if it’s linked to immune system functions and how they’re regulated. More research is needed into how obesity impacts the immune system.


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With individual returns as its focus, this comprehensive course expands on the overview presented in part one, providing extensive detail on real estate, passive los, IRAs and pensions, and gift and estate issues. Combining the real-life experience of a practicing CPA/EA with essential down-to-earth tax materials and a high-tech format, this powerful presentation will enable participants to quickly grasp recent tax changes. You'll receive the most complete and up-to-date reference manual, written by renowned tax expert, Vern Hoven. The digital PDF manual is hyperlinked to the Internal Revenue Code and other primary authorities, making it extremely convenient. Join us as our world-class tax instructors share cutting-edge tax planning strategies in a high energy, often humorous presentation style using real-life experiences, which make complicated tax topics easily understandable. Specific course topics will be announced and updated through year-end.
Upon successful completion of this course, participants will be able to:
- Accurately file returns for individual taxpayers.
- Understand and apply the various IRA and Roth IRA rules in order to properly utilize these vehicles for retirement and tax planning.
- Identify tax issues and apply regulations related to real estate and investment property.
- Identify top estate planning ideas and cutting-edge planning techniques such as family limited partnerships, wealth and succession planning, grantor trusts, and installment sale planning.
- Convey details of the Tax Cut and Jobs Act (TCJA).
- Apply the many other individual tax changes applicable for 2018 returns (these will be updated throughout the year).
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domain: economics


text:
The Role of Surveillance Bronchoscopy Following a Lung Transplantation
- Thoracic Surgery and Lung Transplant Unit Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Division of Pathology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
Academic Editor: Haval Shirwan
Received: July 01, 2020 | Accepted: November 16, 2020 | Published: December 21, 2020
OBM Transplantation 2020, Volume 4, Issue 4, doi:10.21926/obm.transplant.2004129
Recommended citation: Mohamed S, Tosi D, Pieropan S, Cara A, Caffarena G, Croci GA, Rosso L. The Role of Surveillance Bronchoscopy Following a Lung Transplantation. OBM Transplantation 2020; 4(4): 129; doi:10.21926/obm.transplant.2004129.
© 2020 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
Pulmonary transplantation (LuTx) is established as a treatment option for patients with end-stage lung diseases, such as chronic obstructive pulmonary disease, cystic fibrosis, interstitial lung disease, and pulmonary arterial hypertension.
The most recent data from the International Society for Heart and Lung Transplantation (ISHLT) revealed the median survival is 6.7 years for adults who have undergone primary LuTx .
The main causes of death after adult LuTx are acute graft failure and non-CMV infection during the first year and chronic rejection in subsequent years .
To prevent the occurrence of such complications, clinical monitoring is done through pulmonary function tests and procedural methods such as surveillance bronchoscopy, bronchoalveolar lavage, and transbronchial biopsy of lung allografts, which are the most common diagnostic tests.
All lung transplant centers do not use these surveillance procedures as a scheduled or clinically indicated method because, even though the procedure can identify acute rejection in the early stages, allowing early treatment to improve long-term survival, their role in asymptomatic patients is still controversial. Further, this endoscopic technique allows direct visualization of the airways to determine early complications such as anastomotic dehiscence, ischemia, or stricture.
In this review, we aim to analyze the role of bronchoscopy as a surveillance procedure used in determining the presence of infection or rejection and also managing airway complications after LuTx.
We have also discussed the risk and benefit ratio of standard transbronchial biopsy (TBB) and transbronchial cryobiopsy (TCB) as a routine procedure after LuTx.
2. Bronchoscopy after Lung Transplantation
Diagnosis of rejection and infection in asymptomatic patients with lung transplantation could improve the long term survival. Bronchoscopy is a valuable diagnostic tool used as a surveillance procedure. This method uses bronchoalveolar lavage (BAL) to collect the tissue samples for detecting the presence of infection or rejection while assessing airway complications through direct visualization.
The incidence of developing overall lung allograft infections after LuTx is higher than the other organ transplants. Lung allograft is more susceptible to infections due to immunosuppression, exposure to the environment through inhaled microorganisms, and ischemic complications.
Several organisms, specifically fungi, are associated with the development of airway complications at the anastomotic site, such as hemorrhage, bronchomalacia, and bronchial stenosis .
Community-acquired respiratory viruses account for about 30% of all acute respiratory presentations after the LuTx and are also a dominant cause for new respiratory symptoms. Picornavirus, particularly rhinovirus, is the most frequent causative agent for the development of BOS and is recovered in both the upper and lower respiratory specimens, followed by coronavirus and influenza .
Among bacterial infections, Pseudomonas aeruginosa is the most common cause for the development of BOS within the first two years of lung transplantation .
Similarly, fungal infections are also implicated as a potential risk factor for the development of BOS with high morbidity and mortality rates. The most life-threatening issue is related to invasive aspergillosis . An increased risk of BOS is associated with the colonization of the lung allograft with small conidia Aspergillus species and not the larger ones .
One of the latest prospective studies that performed BAL described the most common microbiological findings during the first year of LuTx, where Candida albicans, Pseudomonas aeruginosa, and coagulase-negative Staphylococcus were the most frequent pathogens .
Patients with airway infections could be asymptomatic or may present nonspecific symptoms such as cough, secretions, and fever. These clinical indications need to be diagnosed and treated to avoid sequelae.
Infections in asymptomatic patients can be diagnosed using bronchoalveolar lavage (BAL), including microbiological cultures and PCR performed during the surveillance bronchoscopy to guide antibiotic therapy. Contrastingly, for symptomatic patients, computed tomography (CT) scan and bronchoscopy are suggested.
Bronchoscopy is essential not only for BAL or direct visualization of the bronchial anastomosis but also for operative endoscopy procedures, such as debridement of devitalized tissue, dilation of bronchial stenosis, stent placement, laser, cryotherapy, or biopsies.
After LuTx, both vasculature and airways of the allograft could be affected by an acute, antibody-mediated, and/or chronic rejection. Acute rejection is characterized by a mononuclear cell infiltration around small vessels and capillaries and/or small airways, which establishes a condition called lymphocytic bronchiolitis. Acute rejection and lymphocytic bronchiolitis are risk factors linked to the development of BOS and chronic airway rejection.
The guidelines of the International Society for Heart and Lung Transplantation (ISHLT) describe pathological grading of acute and chronic cellular rejection. The former is based on the presence of perivascular and interstitial mononuclear infiltrates with chronic rejection, while the latter is based on the presence of fibrous scarring that involves the bronchioles and is sometimes associated with the fibrointimal changes affecting the arteries and veins .
Although acute cellular rejection is histologically well defined, there are no standardized diagnostic criteria for antibody-mediated rejection (AMR).
AMR can lead to a range of clinical severity and features, from being asymptomatic with circulatory donor-specific antibody (DSA) through the spectrum to a chronic graft failure.
To create a uniform definition and consensus document for the diagnosis of AMR, the ISHLT multi-disciplinary society convened a working group in 2016 .
This document has identified the following criteria to define an acute pulmonary AMR: allograft dysfunction, DSA positivity, histopathology consistent with AMR, C4d tissue staining, and exclusion of other reasons that cause allograft dysfunction. The degree of confidence in diagnosing AMR is based on the number of criteria present. Clinical AMR is associated with measurable allograft dysfunction, which can be asymptomatic. It may also be sub-clinical, with normal allograft function. Both clinical and sub-clinical AMR were further categorized into three mutually exclusive possibilities (definite, probable, and possible) based on the number of mentioned criteria. “Definite AMR” is identified when all four criteria are met, “Probable AMR” is identified when three criteria are met, or other possible causes have not been excluded, and “Possible AMR” has at least two criteria missing.
Multiple pathological findings of AMR were described in the lung allografts, including capillary inflammation, endothelialitis, and acute lung injury [15,16,17]. The standard transbronchial biopsy(TBBs) is also essential for the detection and diagnosis of AMR.
Chronic lung allograft dysfunction (CLAD) after the LuTx is described as a clinical manifestation with a range of pathological processes in the airway and parenchyma that lead to a significant and persistent deterioration in the functioning of the lung and occurs for more than three months. This chronic condition is considered a major cause of morbidity and mortality after the LuTx.
CLAD may be presented as a predominantly obstructive ventilatory pattern, a restrictive pattern, or a mixed obstructive and restrictive pattern. The most common manifestations of CLAD are bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome, defined by a decrease in the value of FEV1 (amount of air forced from the lungs in 1 s), where FEV1> 20% .
Body plethysmography is recommended to measure Total Lung Capacity (TLC) in the patients at three and six months after the transplant and annually thereafter, and also if FEV1 changes to > 10% from the previous values .
Bronchoscopy with transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL) play a major role in the detection of treatable causes of acute rejection and CLAD, such as acute cellular rejection. However, some controversy is involved in using it as a surveillance procedure in asymptomatic patients.
Histological samples obtained during the surveillance bronchoscopy may detect an area of bronchiolitis obliterans, which is uncommon, as the process is patchy and sampling is limited to a specific site.
2.3 Primary Disease Recurrence
The recurrence of a primary disease has been reported after lung transplantation, and one such primary disease is sarcoidosis, which is the most common, followed by lymphangioleiomyomatosis (LAM), Langerhans cell histiocytosis (LCH), diffuse granulomatous, diffuse panbronchiolitis, and pulmonary alveolar proteinosis.
The clinically indicated cases are usually diagnosed by high-resolution CT of the lungs, followed by the TBB.
Surveillance TBBs can detect the recurrences as incidental findings.
Several authors have reported that ACR may be more frequent and severe among patients with sarcoid recurrence due to a common immunopathological mechanism .
On the other hand, Banga et al. did not observe an increased frequency or severity of ACR with sarcoidosis recurrence and instead found a protective effect. The frequency of ACR episodes among the patients without recurrence of sarcoidosis was similar to those of the ACR rates among patients with different indications on surveillance FB among patients with different indications.
The typical non-necrotizing granulomas seen on TBB specimens in the absence of any other etiology for granulomatous inflammation were pathologically diagnosed.
A histopathological examination of the transbronchial biopsy that reveals spindle-shaped LAM cells with no evidence of infection and acute or chronic rejection is suggestive of LAM recurrence.
Clinically indicated TBB after the LuTx is a valid method to detect the recurrence of primary disease during the surveillance. The TBBs are crucial when the primary disease is still asymptomatic.
3. Surveillance Versus Clinically Indicated Bronchoscopy
Unfortunately, nowadays, there is no consensus on either performing surveillance bronchoscopy or its frequency in patients with LuTx. This controversy is derived from the possible complications related to the endoscopic procedure. For this reason, there are some variabilities in monitoring practices after the LuTx between different centers.
There is a general agreement on clinical monitoring after the LuTx with spirometry, which is widely used as a non-invasive, cheap, and reproducible method. A drop in the FEV1, greater than 10% from baseline, is used to trigger investigations to find any treatable cause . Reduction in the lung function tests, radiological changes, dyspnea, cough, or other similar symptoms are some conditions that require clinically indicated bronchoscopy with BAL and TBB.
In contrast, surveillance bronchoscopy with TBB is performed as a part of a routine protocol in asymptomatic patients after the LuTx.
The protocols of TBB as a scheduled procedure are applied at different frequencies in different centers.
Some centers perform TBB/BAL as a surveillance procedure at 3-6-9-12 weeks after the LuTx. After the first three months, only clinically indicated bronchoscopy is performed. If the first 3 and 6-week surveillance bronchoscopies are found to be normal with negative rejection results, the 9-week bronchoscopy could be omitted [24,25].
However, not all the evidence supports the need for routine surveillance bronchoscopy in LuTx cases. In 2002, Valentine et al., through an observational single-institution study, concluded that clinically indicated TBB/BAL without routine surveillance sampling of the lung allograft does not decrease the survival of the patient with lung transplantation. The same authors in 2008 estimated that over 50% of the centers in the United States performed surveillance bronchoscopies, and despite their small study group, the procedure represented a risk to the lung transplant recipient due to no obvious advantage [26,27].
On the other hand, McWilliams et al. in the same year demonstrated for the first time that bronchoscopy with TBB was a safe procedure in patients with LuTx till the first year. This study analyzed 353 TBBs from 124 patients and confirmed a high diagnostic yield for clinically silent acute rejection and infection .
In 2014, similar results were reported in a retrospective study by Inoue et al., conducted on 206 TBBs from 28 patients who underwent cadaveric lung transplantation. This study reported 49% positive results for surveillance, which showed rejection, infection, or colonization, and 47% for clinically indicated procedures .
More recently, Takizawa et al. assessed 1252 bronchoscopies in 247 patients in a single-center retrospective analysis of LuTx recipients who survived the first year. In this study, surveillance bronchoscopy was sufficient to modify the management, mainly in the 2 and 6-week surveillance bronchoscopies, post-LuTx. Also, they concluded that this effect seems to dilute after the second month, making its applicability questionable  (Table 1).
In our center, the surveillance procedures are performed to monitor lung allografts at 3, 6, and 12 months after the transplant. These scheduled procedures consist of flexible bronchoscopy performed with local anesthesia and intravenous sedation along with bronchoalveolar lavage (BAL) and transbronchial biopsies (TBBs). Samples are usually taken from the 2/3 segments of the right lower lobe (RLL) with a minimum and maximum of 6 and 8 biopsies, respectively, with a single-use 1.8 mm transbronchial biopsy forceps. We preferred RLL because it is possible to place a balloon-based endobronchial blocker in the bronchus intermedius in case of severe and uncontrollable bleeding, allowing ventilation to not only the left lung but also to the right upper lobe. In the case of bilateral lung transplantation, we performed biopsies only in one lung due to the risk of bilateral pneumothorax.
Our experience confirmed the importance of surveillance protocol performed using TBBs or CrioTBBs in patients with LuTx. Of patients involved in the protocol, 8% were diagnosed with AR without any clinical signs, and upon receiving specific medical treatments, the rejection grades were downgraded at the next check-up .
There is still no scientific evidence that demonstrates the need to perform surveillance transbronchial biopsies for the diagnosis of acute rejection in a lung transplanted patient due to the lack of randomized trials.
4. TBB versus TCB
Transbronchial biopsy (TBB) using forceps is considered the gold standard for the diagnosis of acute rejection after the LuTx. However, tissue samples obtained using this technique could be inadequate to assign a pathological grade according to the revision of the 1996 working formulation for the standardization of nomenclature in the diagnosis of lung rejection . In a large percentage of cases, diagnostic inadequacy is due to the crushing artifacts, atelectasis, and hemorrhage within the alveoli .
Transbronchial cryobiospsy (TCB) allows us to obtain larger samples with fewer artifacts compared to TBBs. This technique is largely used for the diagnosis of interstitial lung disease. Despite obtaining larger biopsies with preserved histology, which is free of artifacts and a higher number of alveoli and small airways, only a few studies have reported the use of TCB in lung allografts .
Several studies have compared the two methods in terms of diagnostic adequacy and complications. In 2013, Fruchter et al. assessed the safety and quality of TCB compared to TBB in 80 cases with 40 patients in each group. The mean diameter of the TCB specimens was 10 mm compared to 2 mm of the TBB specimens. The increased specimen diameter resulted in providing adequate tissue in 100% of the cases, whereas in TBB specimens, three nondiagnostic cases were found. No major complications occurred in the TCB group, whereas a single pneumothorax (2.5%) case was observed after TBB. 15% of bleeding events occurred in the TCB group compared to 2.5% events in the TBB group .
In the same year, Yarmus et al. presented the safety profile and biopsy results from 21 procedures, out of which ten were performed using a rigid bronchoscope whereas 11 were performed with a flexible one. Similar to the previous study, the mean specimen size in the TCB specimen was significantly larger and higher in terms of the percentage of sampled tissue containing open alveoli compared to the TBB; these results were also confirmed by other studies later . TBB samples had significant amounts of crushing artifacts, whereas TCB samples demonstrated no evidence of any artifact, including freezing artifact. Only a single case of pneumothorax was described, which also recovered without treatment, and in almost all the cases, there was bleeding that was not severe enough to require surgical intervention or other invasive treatments .
Since 2015, similar complication rates were described in different studies [34,35,36]. The incidence of mild bleeding in TCB groups ranged between 7.5% and 22.5%, except for Gershmann et al., who reported the incidence as 2.5%.
The incidence of pneumothorax in TCB groups ranged between 4.5% and 12.5%, except for Loor et al. who did not report any case. On the other hand, mild bleeding was observed in the TBB groups, ranging between 2% and 14.6%, while pneumothorax was observed up to 4% (see Table 2-3 for detailed results).
Another complication that followed TBBs in patients with LuTx, described in the literature, is the development of new and transient pulmonary nodules (PNs) at the site of biopsies. Mehta et al. hypothesized that these nodules are related to local hematoma and impaired lymphatic drainage. In this retrospective study, PNs were detected in 13% of the procedures within 50 days and needed up to 86 days to resolve spontaneously . These new PNs could be radiologically interpreted as malignancies, opportunistic infection, or post-transplant lymphoproliferative disorder. Based on these results, we suggest that all physicians need to be aware of this iatrogenic etiology to avoid unnecessary workup and radiation exposure. In these cases, close observation is a reasonable management approach.
Recently, we have reported 75 cases of cryobiopsies in 54 lung allograft recipients for surveillance purposes, where only up to 2 samples were retrieved using cryoprobe. Diagnostic rates and complications were described and compared to the TBB data from our previous study. The diagnostic rate of acute rejection using TCB was 100% compared to conventional TBB, where the rate was 83%. Complications described in these two studies were comparable to the previous studies. Moderate bleeding of 6% in the TCB group and 3% in the TBB group were described. Also, only one patient (1%) developed pneumothorax in the TCB group, while 7% developed it in the TBB group [38,25].
Bronchoscopy is a valuable diagnostic tool that is used as a surveillance and clinically indicated procedure. Diagnosis of rejection and infection in asymptomatic patients with lung transplantation could improve the long term survival and avoid sequelae. This method uses bronchoalveolar lavage, which performs tissue sampling to detect the presence of infection or rejection while assessing airway complications by direct visualization.
In conclusion, we recommend surveillance bronchoscopy protocol with BAL and TBB to be performed in all the centers at 3, 6, and 12 months after the transplant. These procedures can allow us to collect specimens from lung allografts with an acceptable risk/benefit ratio and also treat asymptomatic patients with specific medical treatment to reduce the risk of chronic rejection.
Conception of the work: Shehab Mohamed, Davide Tosi, Lorenzo Rosso; Manuscript writing and editing: All authors; Acquisition, analysis, interpretation of data: Shehab Mohamed, Davide Tosi, Lorenzo Rosso
The authors have declared that no competing interests exist.
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domain: biology