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AFRICAN MEDICAL STUDENT WINS THE RESOLUTION FELLOWSHIP AWARD AT THE UNITED NATIONS YOUTH ASSEMBLY

At the closing ceremony of the just concluded UNITED NATIONS 2017 SUMMER YOUTH ASSEMBLY which took place on the 12th of August, 2017 at the United Nations (UN) headquarters Conference building in Manhattan, New York city, OJO ROLAND OLUWAPELUMI  – a 600 level Medicine and Surgery student of the College of Medicine, University of Lagos, Nigeria – was called upon by the Resolution Project Team and announced the winner of the Resolution Fellow Award on the Social Ventures Challenge (SVC) following rigorous presentations and levels scaling among hundreds of participating students and youths present at the conference with wonderful different ideas and projects to impact lives across the world in line with the Sustainable development Goals (SDG).

The Youth Assembly is an annual forum, started since 2002, and a unique platform for fostering dialogue and generating partnerships between exceptional youths, civil society, the private sector and the United Nations to empower future leaders. This year’s summer youth assembly – themed “SOCIETY FOR ALL: Equity and Inclusion for a Sustainable Future” – had about 1,000 delegates in attendance and created different learning, training and investment opportunities to participants such as coding sessions by Microsoft, innovative technology sessions by Wikipedia, World Bank Group sessions and many more.

Aside the Resolution for SVC won by the University of Lagos medical student for the project named “SAFER HANDS” – an initiative in line with SDG 3 to medically and socially reach out to the grassroots and ensure an healthy future for all, especially the younger generation – other featured awards opportunities include outstanding youth delegates, peer mentorship.

The Federation of Medical Students’ Associations (FAMSA) congratulates our fellow, who has represented both his school and also our association well at such great international assembly.

Agoyi Oluwakemisola,
Chaiperson, SCOPUB,
FAMSA.

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FEDERATION OF AFRICAN MEDICAL STUDENTS’ ASSOCIATIONS (FAMSA) 31st GENERAL ASSEMBLY

⁠⁠⁠🌍 Federation of African Medical Students’ Associations (FAMSA)🌍

presents

31st General Assembly

Date 🗓 : 13th-17th September, 2017.

Venue 🏫 : Niger Delta University, Yenagoa, Bayelsa State, Nigeria.

This historic event is an annual platform where medical students from over 30 African countries come together to discuss health issues pertaining to Africa.

Featuring:
🛑 Scientific Seminars/Lectures
⚫ Inter medical school Quiz
🔵 Sight seeing
✳ Native Dinner
🌐 General Election

DELEGATE FEES
➡ Nigerian: $16
➡ Foreign : $32

It promises to be enlightening, fun and adventurous. We look forward to your arrival at Yenagoa!
FAMSA….Towards the improvement of health in Africa

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DEPRESSION – A CALL TO ACTION

The study, published in the Public Library of Science (PLOS) Journal of Medicine, found that globally, the prevalence of depression was 4.4 per cent, while Afghanistan and the Palestinian territories were amongst the most depressed states.

According to the research, depressive orders are second only to lower respiratory infections when it comes to inflicting the most years of disability on people throughout the world.

Clinical depression is defined as involving at least one major episode in which the affected individual experiences a depressed mood almost all day, every day for at least two weeks.

The researchers used data on the prevalence, incidence, remission rates and duration of depression and dysthymia (a milder, chronic form of depression that lasts for at least two years), and on the excess deaths caused by these disorders from published articles.

They found that the prevalence of depression for women was almost twice as high than it was for men.

More than five per cent of people in the Middle East, North Africa, Eastern Europe, sub-Saharan Africa and the Caribbean have depression, the researchers found.

However, it is important to note the research was based on the rate at which people were diagnosed with clinical depression, rather than actual rates of depression.

Maymunah Yusuf Kadiri a consultant Neuro Psychiatrist and Psychotherapist, Medical Director at pinnacle medical service, in an interview with Kemi Ajumobi of Business day newspaper, Nigeria. Depression affects people of all ages, from all walks of life, in all countries. It causes mental anguish and impacts on people’s ability to carry out even the simplest everyday tasks, with sometimes devastating consequences for relationships with family and friends and the ability to earn a living. At worst, depression can lead to suicide, now the second leading cause of death among 15-29-year olds. When mild, people can be treated without medicines but when depression is moderate or severe they may need medication and professional talking treatments. The risk of becoming depressed is increased by poverty, unemployment, life events such as the death of a loved one or a relationship break-up, financial challenges, physical illness, abuse-physical, sexual, emotional and drug, conflicts, economic instability and recession.

There can’t be a better time to spring into action than now when there is an upsurge of depression around the world. At a time where conflicts are daily arising among nations and communities causing economic instability and recession making life more difficult for people especially in Africa and in the Middle East.

According to Prof. Lourens Schlebusch, there are at least 23 suicides a day in South Africa – which may be underestimated due to the stigma involved in suicide. However, data on suicides and other unintentional injury deaths are not systematically tracked by any agency in the country making accurate statistics hard to come by, says SA’s largest mental health NGO, the South African Depression and Anxiety Group (SADAG).

Depression is the most prevalent mental illness in the developing world. In Africa, it’s devastating: 66 million women are suffering. The great majority have no medical services to turn to for help–strong minds.org. If this number of our women ( clinically diagnosed alone)are suffering from severe depressions in a continent Where most women are housewife’s, how will they be able to Take adequate care of our children emotionally. I hope we are not breeding a “depressed future generation”.

From being some of the happiest people on earth, Nigerians have slumped to the rank of the most depressed in Africa. This was the conclusion contained in the latest figures released by the World Health Organisation (WHO), which show that Nigeria has 7,079,815 sufferers of depression, that is 3.9 per cent of the population.

Also, 4,894,557 Nigerians, that is 2.7 per cent of the population, suffer anxiety disorders. The country is closely followed by Ethiopia with 4,480,113 sufferers, that is 4.7 per cent of her population; Democratic Republic of Congo with 2,871,309 sufferers (3.8 per cent); South Africa with 2,402,230 sufferers (4.6 per cent); and Tanzania with 2,138,939 sufferers, that is 4.1 per cent. Seychelles has the lowest number of depressed persons with just 3,722 that is 4.0 percent

One thing about depression is that you can’t sufficiently know how it feels and what debilitating impact it Can have until one goes through depression. Unlike myriads of other clinical illness, it can’t be readily diagnosed and can even be easily missed. It’s like a smothering fire. It gradually and quietly eats away the sufferer’s life. Most of the time, their health parameters may even be normal yet there’s this huge sore in their lives which can’t be picked by any new generation medical diagnostic kit.

Depression is pilfering our lives and future; let’s curb it.

 

AKINDE TITUS GBOYEGA
5th year medical student,
University of Ibadan,
Oyo state, Nigeria.

 

 

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DEPRESSION: A CALL FOR ACTION

On Wednesday 8th October 2014; my re-sit results were out and I failed. I had to re-do my 5th year of medical training. Where do I start? How do I get over this? ‘‘One day at a time….″ I told myself.

As the days turned into weeks, I felt my strength literally leave me. I was going through a downward spiral of mental anguish, unable to carry out even the simplest of tasks; I slept a lot, thought a lot but ate little. Then I figured; I was depressed.

It was difficult, oh yes, it was! Some days, I woke up with the world on my shoulders, some other days, I didn’t just care. I saw myself as a failure, a disappointment to my parents, my relatives, my friends and above all, myself.

I knew I had to act fast, to stop the “haemorrhage”, so i got to my feet and picked myself up again. I began to talk to other medical students who had repeated, I listened to motivational talks and I prayed a lot. Thank God it helped, it wasn’t all rosy but I got better, I felt better…. “All is well that ends well…” I said to myself.

Then it hit me, what about the “other medical students” who had experienced or will experience what I just went through? What about people from other walks of life?  How did or do they cope? Do they know they are depressed? Do they get the help they actually need? Then I concluded; depression is real.

Depression is an illness characterised by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carryout daily activities for at least two weeks (WHO). It affects people of all ages, from all walks of life and in all countries, yes even Cameroon, my country.

It can be long lasting or recurrent, substantially impairing a person’s ability to function at work or school, or cope with daily life. At its most severe, depression can lead to suicide.

According to WHO, depression is the second leading cause of death among 15 -29 year olds.

When mild, depression can be treated without medications but when moderate or severe, people may need medications and professional involvement treatments.

Depression often starts at a young age. It affects women more than men, and unemployed people are also at high risk.

It can affect anyone, no matter your social status. It can be caused by poverty, life events such as the death of a loved one, a relationship break-up, physical illness, and the list goes on and on.

Many of life’s experiences can predispose to depression:

How do you carter for your wife and kids when you just lost your job?

What do you do when you spend several years, looking for a job, but end up sitting at home with your degree in your pocket?

How do you carry on when you suddenly lose a loved one to the cold hands of death or a long term relationship which you cherished so dearly goes to waste?

When faced with such situations, we often feel worthless, useless and helpless. We then use unorthodox methods to mask or alleviate our pain (alcohol, marijuana, etc).

Don’t drown yourself in alcohol, don’t smoke that cigarette. It won’t help.

Find someone you trust; a relative, a friend, a spouse, or a medical professional and talk about it. I did so and it helped. You don’t have to do it all alone. Life is already hard as it is.

Depression is everywhere in our communities; unfortunately, it often goes unrecognized and is frequently attributed to “witch craft″. There’s also very little information available on the subject matter.

Non – specialists can reliably diagnose and treat depression as part of primary health care. Specialist care is needed for a small proportion of people with complicated depression or those who do not respond to first-line treatment.

Depression is treatable; we all have a role to play;

  • The governments health sector should organize awareness campaigns to educate the public on the subject matter.
  • Health care givers should empower themselves through workshops to be able to properly diagnose depression at its embryonic stage.
  • We should all be there for our loved ones when they are feeling down, let’s listen to them keenly, let’s talk with them, let’s let them know that they are not alone. This form of therapy is cheap, effective, and has no side effects.

Depression is more common than we think. Let’s pay attention, let’s talk…

 

NJANG MBENG EMMANUEL,
7TH Year medical student
Faculty of Health Sciences University of Buea,
Cameroon.

 

 

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MENINGITIS OUTBREAK IN SUBSAHARAN AFRICA; A SYNOPSIS

MENINGITIS OUTBREAK IN SUBSAHARAN AFRICA; A SYNOPSIS

BY: IYOKE UYIOSE O. & ODERINDE IYANUOLUWA T.

AUTHORS AS AT TIME OF WRITING: 3RD YEAR CLINICAL STUDENTS, COLLEGE OF MEDICINE, UNIVERSITY OF IBADAN.

IYOKE UO, ODERINDE IT

Department of Medicine and Surgery
College of Medicine
University of Ibadan
Ibadan.
PMB 5116,
Oyo State,
Nigeria.

 

ABSTRACT

In the Sub-Saharan African region, the meningitis belt which comprises of 26 countries has been plagued for over 100 years with recurrent outbreaks of meningitis superimposed on an established endemicity, resulting in significant health and economic burden on affected countries. This article seeks to review literature in an attempt to provide a historical perspective, explore relative risks and challenges across the countries within the belt and proffer possible strategies to improve control of epidemics and outbreaks in the belt.

Keywords: Meningitis, Outbreak, Sub-Saharan Africa, African Meningitis belt

BACKGROUND

Meningitis, an acute inflammatory condition of the meninges, is a debilitating disease characterized by symptoms such as fever, neck stiffness, photophobia, altered mental status. It is caused by various microorganisms (bacteria, viruses, fungi, parasites) with bacterial and viral meningitides being the most contagious1. Meningococcal disease, a contagious bacterial disease is the only known cause of epidemics1-2. Transmission occurs via direct contact with respiratory droplets and aerosols from nose and throats of infected individuals1.

Cases occur sporadically in the west including the US and Europe with incidences ranging from 3-100 per 100000 inhabitants annually2. It is however endemic in the African region particularly across the meningitis belt where incidence rates are as high as 1000 cases per 100000 inhabitants annually2.

THE AFRICAN MENINGITIS BELT

The African Meningitis Belt (AMB), with an estimated population exceeding 400 million people was originally described by Lapeysonnie in 1963 and redefined in 19871,3. The belt stretches from Senegal in the West to Ethiopia in the East of Africa and contains 26 countries; the WHO also refers to the region as the Extended Meningitis Belt1,4. This is because historically; looking at the past 100 years, high rates were present in about 16 countries but in recent times there has been an extension further south. Countries in the AMB include: Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of Congo, Eritrea, Ethiopia, The Gambia, Ghana, Guinea, Guinea Bissau, Kenya, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, South Sudan, Sudan, Tanzania, Togo and Uganda1,4.

Figure 1: Countries within the meningitis belt 22

The AMB designation was sparked by the distinct epidemiological picture observed in bacterial meningitis outbreaks in the region. The region has the highest annual incidence of meningococcal meningitis in the world with superimposed frequent epidemics that constitute a major public health burden4-7.

The most affected countries include Niger, Ethiopia, Chad and Burkina Faso that together account for 65% of the cases in Africa1.

Epidemics within this region occur every 5-12 years with attack rates ranging from 100-800 people per 100,000 to as high as 1% in some communities with children having the highest attack rates during epidemics1,7. Case fatality rates vacillate around 10% despite adequate and appropriate interventions, and 10-15% of affected individuals suffer enduring neurological sequelae e.g. deafness, seizures etc 1,8. In recent times, the epidemics have been occurring sooner and more sporadically8.

Outbreaks within this region occur largely during the hot and dry season indicating that the characteristic climatic conditions of the belt are an important predisposing factor to meningitis epidemics1,4. Local and international travels also favour the spread of virulent strains of meningococci4. Other identified predisposing factors include poor living conditions, overcrowding, and increasing number of internally displaced persons from insurgencies and acts of terrorism4.

THE AFRICAN MENINGITIS BELT; MARKING TIME11-16

The earliest records of meningitis are neither linked to the AMB or Africa. Some notable ancient records dating before the 19th century are found in Greek manuscripts written by Hippocrates and other persons11,15. However, the first reported outbreak occurred in Geneva, Switzerland in 1805 and several epidemics in the United States and Europe followed11. The disease was first linked to a bacterial cause; Neisseria meningitidis in 188711,15, subsequently other causative organisms including streptococcus pnemoniae and Haemophilus influenzae were discovered.

The first outbreak in Africa occurred in 18408, and then outbreaks became more common in the 1900s15.

The 19th Century

This marked a period when the dust of meningitis outbreaks was raised in Africa and it began to find a place to settle. It started with the 1840 outbreak in Algeria11.

The 1840 Outbreak

This occurred in Algeria amongst a French garrison after which it spread to civilians in nearby towns. French troops frequented the country due to colonization by France15. The disease was also found amongst many other French troops around the world. For about a decade before the outbreak, relatively little was heard about meningitis as the disease had calmed in the west since the outbreaks that followed the 1805 epidemic in Geneva8. The epidemic in Algeria would last till 1847 and cause many deaths among the indigenous population as well. Details on the outcome and interventions made are sparse11,13.

This event illustrates the significance of tourism, travel, social and political instability in the spread. This was a theme that recurred throughout the 20th century especially during the world war.

Following this, over 400 outbreaks occurred at subnational levels all over the continent in the following decades up to the 21st century. The outbreaks were not evenly distributed across the continent as they mainly occurred in the Sahel districts. Epidemics across the continent were similar with occurrences in the West although often with higher incidence and fatality rates15.

The 1880s15

Scattered cases were reported in this period in South Africa. Mining compounds had favourable conditions for meningitis, with newly hired African workers forced to live in conditions similar to those of military recruits.

Figure 2: Pictorial depiction of events in the 19th and 20th century5

The 20th century

This period witnessed the hugest surges of meningitis in Africa and a polarize to the Sub-sahara and the AMB11-17.

The initial area for the epidemic CSM, however, was the savanna zone south of the Sahara Desert from Sudan to Senegal. This area was swept by a series of great epidemics during the century      15.

The 1905 Epidemic

The first of the great African epidemics began in Northern Nigeria in early 190515,16. It spread westward as far as Mali and northwest Ghana in 1906, enduring in those places until rains came in 1908. Total deaths were not known but have been guessed to reach 34,000 in Ghana; case mortality was estimated at 80 percent15. Although there are no clear records due to ill medical and political systems, there clearly was a major disaster in this period.

By 1910 it was established that the meningococcus was solely responsible for epidemics and that other bacteria rather cause sporadic cases13,15-16.

In the West, there was some success in vaccination against diphtheria during this time, hence numerous efforts were made to develop a therapeutic serum and active vaccines against meningococcal meningitis15. Four serotypes were discovered due to varied vaccination successes15.

Epidemiologists posit that pilgrims and/or soldiers infected in Sudan imported the disease to Northern Nigeria14. The month it would have taken soldiers and pilgrims to travel from Sudan to northern Nigeria by camel would likely have been within the time period that the microorganisms remained alive in the nasopharynx of the travelers. The disease was notorious for asymptomatic carriage11-15.

The Second CSM Cycle

After the 1905 outbreak, subsequent large and deadly outbreaks tended to occur every 5-10 years, usually during the winter months of the meningitis belt2,16. The second cycle started in northwest Ghana in 1919, spread to Burkina Faso in 1920, and swept northern Nigeria and Niger from 1921 to 19241. Weak political and medical infrastructures impeded accurate estimates of cases or deaths, nonetheless the death toll in one northern Nigerian province, Sokoto, was put at over 45,000 in 1921 alone, and it is assumed that over the 4-year period at least 15,000 persons died in Niger15.

Around this time there was development of the group A vaccine15.

Some challenges encountered was difficulty of the Europeans in introducing the vaccines to affected regions. Natives of affected regions rebelled against moves made by the colonial medical authorities as they had previously imposed harsh measures of isolation on communities and households. Households tended to hide their affected members to avoid the surveillance radar15.

 

The 3rd CSM cycle

This started in West Africa in 1935. Chad was attacked by an epidemic which was noticed to be to an outbreak that occurred during the previous year in some provinces in Central Sudan. This was the first time that a clear pattern of east-west spread from Sudan was demonstrated. Carriers brought infection westward during the rainy seasons to Chad, to northern Nigeria, and thence to Niger, with disastrous epidemics following. This contributed to the discovery of the important epidemiological role of asymptomatic carriers16.

This CSM outbreak hit Burkina Faso, Mali and northern Ghana in 1938-1939. Local outbreaks continued through 1941. Mortality statistics are very unreliable, majorly due to poor health systems and households/communities avoiding the surveillance systems of colonial masters. There was a breakthrough against the disease with the advent of sulfa and penicillin drugs, the sulfa drugs reduced mortality from 50-80% to 20% but still several tens of thousands died. French efforts to protect Africans against serogroup A by vaccination had inconclusive results, and similar British trials in Sudan were unsuccessful11-13.

CSM remained epidemic for close to 10 years after across the belt. Major outbreaks where continually reported from Chad to Senegal. Burkina Faso, western Niger, and northwest Ghana were particularly afflicted.

The disease with the outbreaks had fairly settled in the region. More cycles of epidemics developed in 1949 from foci in northern Ghana, northern Nigeria, and Burkina Faso, spreading eastward as far as Sudan by 1952. Geographic patterns of spread became much less distinct.

Between 1905 and 1960, epidemiologists speculate that up to a million or more-people died of CSM in the belt, especially in West Africa.

In 1996, a large epidemic was recorded which killed 25000 in Africa2,5,7

The 21st Century in Pictures5                                         

 

RISK ACROSS COUNTRIES IN THE BELT

Dry seasons

Dusty and dry environments are strong predictors of meningococcal epidemics. It is hypothesized that inhaled dust particles cause small cuts the mucous membranes, allowing N. meningitidis microbes residing in the throat get into the bloodstream and underlying tissues, causing infection9,10,20.

Changing seasons

Meningococcal epidemics usually cease with the onset of wet/rainy season. They tend to occur in places that have a distinct wet season in addition to a dry season. Meningococcal epidemics are less likely in deserts and humid forests9. Seasonal hyperendemicity is common in the dry season between January and May13,20.

Socioeconomic factors

Poverty experienced by a lot of Sub-Saharan residents contributes to the severity and frequency of meningococcal meningitis [MNM]. Effective vaccines for the epidemic strains of MNM are accessible but significant proportion of the population in the belt lack the financial resources required for routine preventative vaccinations and this is the population usually affected. They depend on outside organizations such as the WHO for free or subsidized vaccinations9,11.

 

Migration

History has shown that the disease is importable and exportable.

Resource Inequalities

Resources, infrastructure and access to primary care needed to prevent, detect and treat meningitis tends to be polarized to well-developed communities or individuals who can afford it.

High Population densities

Regarding annual incidences, population density has not been found significant but recurrences tend to occur in highly populated communities.

Immune suppression

Immune system suppressing diseases are still significant problems in Sub-Saharan Africa. Amongst individuals, symptoms of upper respiratory tract infection were associated with asymptomatic carriage during epidemics in communities8,20. Furthermore, flu symptoms were associated with subsequent meningococcal meningitis; this relates to immune depression that results from viral infections like influenza and pneumococci. The importance of this was illustrated in 2012 by a monthly incidence of meningitis in Ghana which was associated with a simultaneous incidence of pneumonia20. Malnutrition, poverty as well as diseases like HIV serve as harbingers for immunosuppression that ravage a lot of countries in the region.

Diet

Malnutrition in children is a singular risk factor for immunosuppression which predisposes to the illness. Green foods in Burkina Faso were implicated in the disease. Green mangoes and green food laden with dust mostly consumed by children, during the hot season activated the disease in those who had predisposition20-21.

 

IMPACT ON THE COUNTRIES WITHIN THE MENINGITIS BELT

With over 400 million people at risk within the belt, the impact of these epidemics on the people as well as on the economy of affected countries is immense.

Families, communities, and indeed the country at large is left devastated and depleted of essential resources, further exacerbating the already pervasive poverty and preventing substantial development. On an individual level, caring for family members with meningitis is a huge financial burden. For instance, households in Ghana lose an average of 29 days of work per case and households in Burkina Faso [1] spend up to US$90 per case (34 percent of annual GDP per capita)2. For households struggling to make ends meet under normal circumstances, the costs are unmanageable.

In 1995, infectious diseases like meningitis contributed to approximately 42.5% of lost DALY’s. As reported by the WHO in 2002, an estimated 891 DALYs were reported to be due to meningitis, indicative of the fact that valuable productive years of the lives affected individuals are lost22. Colombini et al in a study conducted in Burkina Faso in 200822, a country at the heart of meningitis outbreaks, reported that students affected by meningitis lost 12 days of school due to the disease. The study also revealed that employed adults lost an average of 21 days of work due to meningitis. Lost days of work, reduced productivity, and the cost associated with the disease all contribute to reduced quantity and quality of the labour force and consequently minimal economic growth. These countries were therefore in a vicious, unrelenting cycle of unproductivity and lack of development. Disease results in lack of economic growth which in turn prevents development which could potentially reduce disease burden.

Control and prevention of epidemics require massive amount of vaccines, medicines, and logistic support from national health authorities of affected countries resulting in diversion of funds, material and human resources necessary for maintenance and improvement of routine health service delivery of affected countries22.

 

THE WAY FORWARD21

Epidemic preparedness

The majority of countries burdened by recurrent outbreaks of meningitis are not adequately prepared to cope with such emergencies, the need to reinforce national capacity for preparedness, detection and control of epidemic meningitis has been recognized internationally.

To respond to this challenging situation and to the expected spread of the disease, WHO, in collaboration with its member states and various governmental and non-governmental agencies, has developed a sustainable plan of action for preparedness and control of meningococcal disease in the African and Eastern Mediterranean Regions. This initiative focuses on strengthening national and regional health systems in the following key areas:

  • Surveillance of communicable diseases for timely detection of outbreaks;
  • Laboratory capacity for diagnosis of communicable diseases and rapid confirmation of outbreaks;
  • Creation of a contingency stock of vaccine, antibiotics and injection materials and establishment of a revolving fund to ensure immediate availability of these materials in emergencies;
  • Production of guidelines for the use of vaccine and protocols for appropriate case management.

While this international initiative was triggered in response to a crisis in vaccine supply for the control of severe epidemics of meningitis in Africa, it now ensures advance preparation for epidemics, with better surveillance to detect outbreaks promptly, and supplies ready for immediate dispatch to affected countries.

Global partnerships

As part of the WHO initiative for preparedness and control of epidemics in Africa, the International Coordinating Group on Vaccine Provision for Epidemic Meningitis Control (ICG) was set up to coordinate the best use of the limited amount of vaccine available, to ensure that the meningitis vaccine was used where it was needed most and that wastage was avoided. The ICG is composed of representatives of UNICEF, the International Federation of the Red Cross and Red Crescent Societies (IFRC), Medecins Sans Frontières (MSF) and WHO, as well as technical partners from WHO Collaborating Centres and manufacturers of meningitis vaccine, antibiotics and autodestruct syringes.

The objectives of the ICG are:

  • To ensure the availability and rational distribution of emergency supplies of meningococcal serogroup A and C vaccine to countries experiencing epidemic meningococcal meningitis;
  • To ensure timely availability of vaccine in countries experiencing epidemics;
  • To coordinate international efforts in preparing for, and responding to, epidemic meningitis.

Other WHO meningococcal meningitis programmes.

Ongoing activities include:

  • Operational research to determine best strategies for deploying meningitis vaccine;
  • Development of treatment, laboratory and epidemic control guidelines;
  • Laboratory strengthening to ensure prompt and accurate diagnosis;
  • Surveillance to gain more information on the occurrence of meningococcal disease and give a rapid alert for epidemics.

CONCLUSION

Considering the massive socioeconomic impact of meningitis epidemics over the past several decades, the importance of improved surveillance, notification, and adequate preparedness as well as improved funding and provision of vaccines cannot be overemphasized. Health education and community participation is also essential in the fight against the meningitis in sub-Saharan Africa.

REFERENCES

  1. Ahmed-Abakur EH. Meningococcal Meningitis: Etiology, Diagnosis, Epidemiology and Treatment. American Journal of Medicine and Medical Sciences. 2014;4(6):266-71.
  2. Meningococcal disease in other countries. Center for disease control and prevention. https://www.cdc.gov/meningococcal/global.html (accessed on 05/17)
  3. Meningitis and Africa. African Meningococcal Carriage Consortium
  4. Meningococcal Meningitis (2015). World Health Organization. http://www.who.int/mediacentre/factsheets/fs141/en/
  5. Marking time with meningitis. http://www.path.org/menafrivac/timeline.php
  6. Kebede S, Duales S, Yokouide A, Alemu W. Trends of major disease outbreaks in the African region, 2003-2007. East Afr J Public Health. 2010 Mar 1;7(1):20-9.
  7. Dr Ananya Mandal, MD. History of Meningitis http://www.news-medical.net/health/History-of-Meningitis.aspx
  8. Lingani C, Bergeron-Caron C, Stuart JM, Fernandez K, Djingarey MH, Ronveaux O, Schnitzler JC, Perea WA. Meningococcal meningitis surveillance in the African meningitis belt, 2004–2013. Clinical infectious diseases. 2015 Nov 15;61(suppl 5):S410-5.
  9. Jafri RZ, Ali A, Messonnier NE, Tevi-Benissan C, Durrheim D, Eskola J, Fermon F, Klugman KP, Ramsay M, Sow S, Zhujun S. Global epidemiology of invasive meningococcal disease. Population health metrics. 2013 Sep 10;11(1):17.
  10. Eliminating Meningitis Across Africa’s Meningitis Belt. Centre for Global Development. http://millionssaved.cgdev.org/case-studies/eliminating-meningitis-across-africas-meningitis-belt
  11. The History of Meningitis. http://bbacterialmmeningitis.weebly.com/history.html
  12. Molesworth AM, Cuevas LE, Connor SJ, Morse AP, Thomson MC. Environmental risk and meningitis epidemics in Africa. Emerging infectious diseases. 2003;9(10):1287-93.
  13. Editorial: 100 years of epidemic meningitis in West Africa – has anything changed? Brian Greenwood Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
  14. Chalmers AJ, O’FARRELL WR. Preliminary Remarks upon Epidemic Cerebrospinal Meningitis as seen in the Anglo-Egyptian Sudan. Journal of Tropical Medicine and Hygiene. 1916;19(9).
  15. http://www.history-of-world.com/history_of_human_disease/18164-history-and-geography.html
  16. Meningitis in West Africa. https://microbewiki.kenyon.edu/index.php/Meningitis_In_West_Africa
  17. Sultan B, Labadi K, Guégan JF, Janicot S. Climate drives the meningitis epidemics onset in West Africa. PLoS Med. 2005 Jan 25;2(1):e6.
  18. Robbins JB, Schneerson R, Gotschlich EC, Mohammed I, Nasidi A, Chippaux JP, Bernardino L, Maiga MA. Meningococcal meningitis in sub-Saharan Africa: the case for mass and routine vaccination with available polysaccharide vaccines. Bulletin of the World Health Organization. 2003 Oct;81(10):745-50.
  19. Ending meningits A in Africa. http://www.path.org/menafrivac/overview.php
  20. Agier L, Martiny N, Thiongane O, Mueller JE, Paireau J, Watkins ER, Irving TJ, Koutangni T, Broutin H. Towards understanding the epidemiology of Neisseria meningitidis in the African meningitis belt: a multi-disciplinary overview. International Journal of Infectious Diseases. 2017 Jan 31;54:103-12.
  21. Meningococcal Disease: Public health burden and control (WHO). Can be accessed at http://www.who.int/emc/diseases/meningitis/index.html
  22. Burger L. Economic Burden of Meningitis in Sub-Saharan Africa and the Importance of Vaccination Programs: A Case Study of Niger.

 

 

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MENINGITIS OUTBREAKS :THE DRY SEASON IS COMING

Meningitis-an acute inflammation of the meninges of the brain and spinal cord- may be suspected when there’s a sudden onset of fever (>38.5 oC rectal or >38.0 oC axillary) and any of the following signs: stiff neck, bulging fontanelle, convulsion or other meningeal signs. However, isolation of the causal pathogen: Neisseria meningitidis, Streptococcus pneumoniae or Haemphilus influenzae type B from the cerebrospinal fluid of an individual gives you a confirmed case of meningitis.

Although cases occur worldwide, an extensive region of Sub-Saharan Africa- The Meningitis Belt– has had recurring epidemics over the years. This region comprising of 26 countries from Senegal in the west to Ethiopia in the east has the reason for its susceptibility in part related to its climatic features with outbreaks occurring mainly in the hot, dry and windy months of the year. Studies have shown that epidemic meningitis has been dwelling in Africa for the past 100 years with waves featuring every 8-12 years and lasting for two to three years.

On vaccines and bacterial serogroups, over a million cases have been reported in Africa since 1988 with most caused by Neisseria meningitidis Serogroup A. However, there has been a massive reduction of the A trend due to the successful roll-out of MenAfriVac- a conjugate vaccine developed to curb this particular sub-type A serogroup by making it affordable and tailor-made. In fact, since its introduction in 2010, it has reduced the occurrence of meningitis in Chad alone by 94% and the whole continent by 57%, vaccinating more than 260 million individuals across 19 countries. Thanks to the Bill and Melinda Gates foundation for the US $70 million grant of 10 years that kick-started the Meningitis Vaccination Project, a partnership between PATH and the World Health Organization (WHO). The foundation charged the project with the development, testing, licensure and mass introduction of a meningococcal conjugate vaccine. However, outbreaks in Togo and Nigeria recently have had serogroups W and C respectively as the dominant cause of the epidemics. This calls for a close monitoring of the changing epidemiology of meningococcal disease as well as a review of the current strategy by the WHO in tackling it.

Finally, these epidemics usually strain the delivery of routine healthcare services as emergency treatment centres are set up as well as catastrophically increase the healthcare expenditure of people. A study carried out in Burkina Faso discovered that households spent US $90 per meningitis case and up to US $154 more when meningitis sequelae occurred (Colombini A, et al). You can imagine the depletion of household resources in these developing or worse still, impoverished countries.
My heart goes out to the families of those who lost their lives to meningitis.

ALUKO OLUWABUSAYO DANIEL
COLLEGE OF MEDICINE, UNIVERSITY OF LAGOS, NIGERIA
+2348179380972

oluwabusayoaluko@gmail.com                                                                

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WORLD HYPERTENSION DAY- KNOW YOUR NUMBERS

The World Hypertension Day (WHD) is an annual event celebrated on May 17, with the main purpose of promoting public awareness of hypertension and to encourage citizens of all country to prevent and control the silent killer.

 

The theme for this year’s World Hypertension Day is Know your numbers.

Hypertension (High Blood Pressure) is defined by Mayo Clinic as a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease.

Hypertension is the leading risk factor for disease burden worldwide, and it is the #2 cause disease burden in developing countries. Over 1 billion people all over the world suffer from hypertension and it’s predicted to increase by 60% in 2025.

According to the International Society of Hypertension, approximately 4 in 10 adults have raised blood pressure which often goes undiagnosed and one big reason for this is that one can have hypertension without any symptoms for years. Fortunately, hypertension is one of the easiest conditions to diagnose, all it needs is a blood pressure measurement. Every adult should be aware of their blood pressure values and should also check them constantly.

Blood pressure measurements fall into four general categories:

  • Normal blood pressure.Normal if it’s below 120/80 mm Hg.
  • Prehypertension is a systolic pressure ranging from 120 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. Prehypertension tends to get worse over time.
  • Stage 1 hypertension.Stage 1 hypertension is a systolic pressure ranging from 140 to 159 mm Hg or a diastolic pressure ranging from 90 to 99 mm Hg.
  • Stage 2 hypertension.More severe hypertension, stage 2 hypertension is a systolic pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher.

After the diagnosis of hypertension is made, it can be easily managed with dietary therapy and drugs.

Hypertension is preventable! Simply put, Healthy attitudes can combat hypertension. Like every disease in our world today, prevention is better than cure. In the case of hypertension, it’s all about healthy attitudes which are outlined below:

  • Eating a healthy diet
    Various nutrition guidelines are published by medical and government institutions to educate the public on healthy diets.
  • Reducing salt content in the diet
    Limit salt/sodium consumption from all sources and ensure that the salt is iodized.
  • Increasing physical activity
    The World Health Organization (WHO) recommends at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.
  • Maintaining a healthy weight
    The Body Mass Index (BMI) is generally accepted as an objective way of assessing the weight of an individual. The normal BMI is 18.5-24.9kg/m2.
  • Maintaining a healthy attitude towards alcohol intake
    Chronic alcohol consumption is associated with many conditions including hypertension. Guidelines on alcohol consumption published by medical institutions are readily available.

 

Hypertension generally develops over many years, and it affects nearly everyone eventually. Fortunately, high blood pressure can be easily detected. And once you know you have high blood pressure, you can work with your doctor to control it.
One important thing is to get evaluated, know your blood pressure numbers.
Remember, Hypertension is a silent killer! Prevention is Key, get to know your numbers!

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COLON CARCINOMA: PECULIARITIES IN NIGERIA. A REVIEW.

COLON CARCINOMA: PECULIARITIES IN NIGERIA.  A REVIEW.

BY: EROMOSELE BENJAMIN O.

AS AT TIME OF WRITING, 2ND YEAR CLINICAL STUDENT, COLLEGE OF MEDICINE, UNIVERSITY OF IBADAN, IBADAN.

EROMOSELE BENJAMIN OSEIWE
Department of Medicine and Surgery,
College of Medicne,
University of Ibadan,
Ibadan.
PMB 5116,
Oyo State,
Nigeria.

 

ABSTRACT

BACKGROUND

Typically referred to as a disease of Caucasians, the incidence of colon carcinoma is growing in Nigeria. In this review, factors that may be accounting for this trend are looked at, as well as the peculiarities of the disease in Nigeria and Africa at large.

Colon carcinoma in Nigeria comes with its peculiarities such as, late presentation; such that most cases present at an advanced stage with incurable disease, increasing adoption of ‘Western’ diets and lifestyle; such as, consumption of high fat, low fibre diet, and reduced physical activity, which is suspected to be responsible for the increasing incidence of the disease, and a paucity of polyposis coli syndromes.

The aim of this review is to emphasize;

  • that colon carcinoma is not a disease of only Caucasians and that the incidence is even increasing among native Africans
  • the peculiarities of this disease among Nigerians in particular and Africans at large
  • the pointers to early diagnosis
  • preventive measures to this potential epidemic

MATERIALS AND METHODS

The materials used in this review article comes from studies and publications on colorectal carcinoma.

KEYWORDS

Colon, carcinoma, peculiarities and review.

INTRODUCTION

Colon carcinoma in traditional descriptions, is said to be uncommon among native Africans. Once the 10th most common malignancy in men from the Ibadan cancer registry four decades ago (1960 to 1969), now holds as the fourth most common malignancy [1]. This shows an increasing incidence.

Even with an increasing incidence, reports estimate that about 6 to 25 patients present annually in Nigerian tertiary health care centers[2-9]. This shows that it is still relatively uncommon compared to other westernized societies. Awarness must be put in place to halt this potential ‘outbreak’, considering resource constraint on the part of the government in solving issues such as this in Africa, with Nigeria in particular. This is further complicated by the fact that most Nigerian patients present late with advanced disease, with a significant proportion in comparison to Caucasian cases, being the mucin-producing adenocarcinoma which carries a worse prognosis [10].

In contrast to other westernized societies, there is a paucity of polyposis coli syndromes among Nigerians [10] such as Lynch syndrome which confers a hereditary predisposition to colon cancer. In Nigeria only four cases of adenomatous polyposis have been reported in the last thirty five years [11,12,13,14]. The mean age incidence of colon carcinoma in Nigeria is 41 years, with Ibadan as reference [15], with an incidence rate of 3.4/100,000[16], the increasing incidence may be attributed to an increasing adoption of westernized lifestyle, increasing life expectancy; due to an increasing access to better health care, since colon carcinoma is sometimes referred to as a disease of aging[17], among other reasons.

DISCUSSION

With an increasing incidence of colon carcinoma in Nigeria, the peculiarities of the typical Nigerian picture of colon carcinoma are discussed below

Pathogenesis

The carcinogenesis of colonic carcinoma among Nigerians is somewhat controversial. The typical adenoma-carcinoma sequence seems unlikely among Nigerians [4,15,18,19]. This is supported by the fact that studies show that it takes fifteen to twenty years for malignant change to occur in an adenoma[9,20], making it unlikely in Nigerians since the age incidence of clinical disease is relatively commoner among the younger age group. The microsatellite instability theory holds true more commonly for hereditary nonpolyposis colorectal carcinoma [21], which is rare among Africans.

This raises the suggestion that most cases of colon carcinoma in Nigeria occur sporadically, with an adequate environmental influence.

Presentation

The clinical presentation depends on the site affected. The most common site in Nigeria appears to be the caecum [10], which may present as an abdominal mass [17]. In right sided disease, presentation is usually that of an iron deficiency anemia due to chronic blood loss. In left sided disease, the features are those of obstruction such as change in bowel habit, chronic constipation; since the stenosing variant of colon carcinoma seems more common here [17]. In the transverse colon, the features here are determined by the proximity to either the right or left side. If closer to the right, features are similar to right sided disease and if close to the left; features are similar to those of left sided disease. Bleeding per rectum, hemorrhoids due to obstruction of the superior rectal vein [17] and tenesmus may also be seen. It is also noteworthy that most patients present late in Nigeria. Orthodox and traditional means are usually first sought before hospital presentation, causing most patients to present late with advanced and incurable disease. Most times in this case, palliative care may be offered with chemotherapy. In operable cases, surgery may be offered.

In this group of patients features in keeping with advanced disease such as weight loss due to elaboration of cachexin (TNF alpha), malignant peritonitis, colo-vesical fistula, colo-vaginal fistula and a host of other features due to local invasion, tumor infiltration and distant metastasis are seen.

Histologic Subtype and Mode of Spread

The mucin-producing adenocarcinoma has a higher proportion among native Africans compared to Caucasuians (it occurs in native Africans in a percentage of thirteen to twenty; while it occurs among Caucasians in a percentage of four to six) [34]. It is also known to carry a bad prognosis [10]. It is defined as a tumor displaying extracellular mucin in more than 50% of the tumor volume [22]. New evidence is showing that mucin-producing adenocarcinoma may have a distinct biological and genetic identity compared with non-mucinous adenocarcinoma [23,24]. Patients with mucin-producing adenocarcinoma are usually younger [25,26]; which most Nigerian cases fall into due to average life span demographics. In addition, these tumors may have distinct mutations and cytogenic abnormalities [23,27], and may be less likely to respond to chemotherapy[28-30]. These tumors are commonly right sided [31-33], and associated with advanced disease [24,25,31,32], which holds true for most cases in Nigeria

Spread may be by;

  • Direct infiltration, usually by a transverse means to encircle the bowel wall. Microscopically it does not spread beyond 5cm of the macroscopic edge longitudinally [17]. Thus the affected segment must be resected at least 5cm beyond the tumor edge [17].
  • Lymphatic spread first to the paracolic lymph nodes and through the intermediate nodes to the inferior and superior mesenteric lymph nodes [17]. The frequency of lymph node metastases is directly related to the degree of penetration of the intestinal wall and the histologic grade of the malignancy and not necessarily the size of the primary lesion [17].
  • Spread through the blood stream is usually through the inferior or superior mesenteric veins, and the portal vein; to the liver (33%), less frequently to the lungs (22%), adrenals (11%), kidneys and bone (11%) and the brain.[17]
  • Transperitoneal spread which may result in malignant peritonitis with ascites.

Risk Factors

The role of diet in the epidemiology of colon carcinoma is one that has been extensively studied [34]. Most traditional Nigerian diets are said to be protective due to its high fibre, mineral and vitamin content from locally available fruits and vegetable, high spice and pepper content [34], which translates to higher antioxidant levels. Local Nigerian diets are majorly carbohydrate based which has been shown to have protective effects too [34]. The high sunlight exposure Nigeria enjoys [34], appears to afford us more vitamin D, which is colon carcinoma protective.

The increasing incidence of colon carcinoma may be traced to adoption of westernized diets due to affluence. Most westernized diets have a low fibre and high fat content, which has been repeatedly shown to be a risk factor for colon carcinoma [37,38]. Intake of fruits and vegetables is reducing among Nigerians, with a concomitant reduced intake of minerals, vitamins, antioxidants and fibre contained in them, which are cancer protective [34].

The increasing adoption of tobacco smoking among Nigerians may also account for an increasing incidence of colon carcinoma [39].

Excessive alcohol intake has also been shown to be a risk factor for colon carcinoma and gastro-intestinal cancers in general, it is thought to be due to production of acetaldehyde which is a known carcinogen [35,36]. Due to increasing affluence among Nigerians, alcohol consumption is on increase.

Adoption of sedentary lifestyles with reduced physical activity is a risk factor for obesity. Obesity has been linked with colon carcinoma development [37,38]. Sedentary lifestyles are associated with less sunlight exposure, which amounts to less vitamin D in the body, with therefore an increased colon carcinoma risk, since vitamin D is known to be colon carcinoma protective [34].

The adoption of westernized lifestyle has been linked to increasing affluence among Nigerians and an ever increasing influx of foreign processed foods; most of which are associated with cancer risks, from developed countries into Nigeria.

Treatment options

Modality of treatment to be used is governed mainly by the stage of presentation and site affected.

Surgical treatment [17]

  • Caecum, ascending colon and hepatic flexure; right hemi-colectomy, that is resection of the last 15cm of the terminal ileum, ascending colon and proximal two-thirds of the transverse colon with ileo—transverse anastomosis
  • Transverse colon; resection of the transverse colon and both flexures
  • Splenic flexure; left hemi-colectomy that is resection of the distal colon and distal two-thirds of the transverse colon.
  • Descending colon; same as splenic flexure, but a more radical resection with removal of the pelvic colon is preferable.
  • Pelvic colon; pelvic colectomy with or without left hemicolectomy

Treatment is most commonly by open abdominal surgery using diathermy, stiches and staples.

Radiotherapy

It is given preoperatively if the tumor is tethered or with evidence of extra-peritoneal spread and/or positive lymph nodes or post-operatively if a tumor turns out to be Dukes’ B2 or C [17]. Radiotherapy may also be offered as a palliative measure in advanced disease.

Chemotherapy

5- fluoro uracil, an antimetabolite cancer chemotherapeutic agent is the major agent used. Leucovorin is usually added as an adjunct due to the associated risk of bone marrow suppression which may cause severe neutropenia. Other agents which may be used in combination with 5-flouro uracil, include the platinum based chemotherapeutic agent, oxaliplatin and irinotecan, a topoisomerase 1 inhibitor.

Bevacizumab is a humanized monoclonal IgG antibody which binds and neutralizes vascular endothelial growth factor (VEGF), which has shown so much promise with its use in the western societies, but with limited use in Nigeria due to cost implications.

Screening

Even though not yet realistic in this environment due to relatively low incidence rate, it is commonly practiced in high risk groups in the western societies, where it has become of public health concern. It includes;

  • Fecal occult blood sampling
  • Sigmoidoscopy
  • Colonoscopy

  

Conclusion

Colon carcinoma a major cause of morbidity in the developed climes and is gradually taking its root in Nigeria in particular, and Africa as a whole. This has been largely due to adoption of westernized lifestyle due to increasing affluence among Nigerians. Control and preventive measure must be put in place to stem this growing problem which has the potential to take its toll in Africa, being a resource poor environment.

Acknowledgement

I want to specially acknowledge Dr. D.O. Irabor; Consultant Gastro-Intestinal Surgeon, who has spurred my interest in the field of gastro-intestinal surgery due to his prowess as a teacher and great skill as a surgeon. I also appreciate him, for accepting to be the Supervising Consultant of this review article, and for being my mentor and role model.

References

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  14. B. J.  Olasode  and  O.  A.  Olasode,  “Missed  diagnosis—adenomatous  polyposis  coli,”  The Central African  Journal  of Medicine,  vol.  43,  no.  11, article 339, 1997.
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POSTPONEMENT OF THE 2017 FAMSA GENERAL ASSEMBLY

This is to inform all those concerned that the Federation of African Medical Students’ Associations (FAMSA) General Assembly earlier scheduled to hold at the Niger Delta University from 15th – 19th of March, 2017 has been postponed till further notice.
All activities as regards this event should be stopped immediately. We regret any inconveniences caused.
This message is from the FAMSA Secretariat and the FAMSA Headquarters.
For inquiries contact:+2347066677796
famsaarchives@gmail.com
✍🏽 Zita Onaga,
FAMSA Administrator.

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INTERNATIONAL WOMEN’S DAY

 INTERNATIONAL WOMEN’S DAY (#BeBoldForChange)

Did you know that women in New York were denied voting rights,  equal pay with the counterpart males and had to work for longer hours until the great women protest in 1908 that involved over 15000 women who marched through the city of New York demanding equal rights and pay?”

Did you know that the international women day was originally observed as National Women’s Day on the 28th of February only in America,  until 1910 when CLARA ZETKIN,  (Leader of the ‘Women’s Office’ for the Social Democratic Party in Germany) tabled the idea of an International Women’s Day at the second International Conference of Working Women was held in Copenhagen?

You may have heard that on the last Sunday of February, Russian women began a strike for “bread and peace” in response to the death of over 2 million Russian soldiers in World War 1. Opposed by political leaders, the women continued to strike until four days later the Czar was forced to abdicate and the provisional Government granted women the right to vote in Russia.

Over the years,  great women of different colours and races have risen amidst surrounding oppression and injustice to speak against injustice to the woman folk,  to say yes to gender equality and female Education! To say no to racism and even yes to world peace and stability!

International Women’s Day (March 8) is a global day celebrating the social, economic, cultural and political achievements of women. The day also marks a call to action for accelerating gender parity. This day has been observed since in the early 1900’s – a time of great expansion and turbulence in the industrialized world that saw booming population growth and the rise of radical ideologies that almost silenced the woman race

This year’s theme focuses on “Women in the Changing World of Work: Planet 50:50 by 2030”

For International Women’s Day 2017, we’re asking you to #BeBoldForChange
We Call on the masses to help forge a better working world – a more inclusive, gender equal world

Let’s join the voices of the Great Ida Bells, Lee Tai-young, Sally Ride,  Miriam Makeba, our very own Chimamanda Adichie to say Yes To A Gender Equal World

In the words of world-renowned feminist, journalist and social and political activist Gloria Steinem, “The story of women’s struggle for equality belongs to no single feminist nor to any one organization but to the collective efforts of all who care about human rights”

So make a difference, think globally and act locally!
Make everyday International Women’s Day.
Do your bit to ensure that the future for girls is bright, equal, safe and rewarding.

Spread the word today!

Happy March 8!  Happy Women’s Day!!
The Federation of African Medical Students’ Associations (FAMSA) is saying yes today TO A GENDER EQUAL WORLD

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