risk factors for cervical cancer and prevalence of precancerous

Report
Risk Factors of Cervical Cancer and
Prevalence of Precancerous Cervical
Changes among Sexually Active
Women in Lagos, Nigeria
Olawunmi O. Adeoye¹, O. Fawole², I. Ajayi², O. Biya¹, P. Nguku¹
1.
Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
2.
Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan,
Nigeria
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Introduction
• Cervical cancer (CC) is a major public health problem
• The second most common cancer in women globally
• About 500 000 new cases and 250 000 deaths yearly
• Characterized by precancerous cervical changes (PCC)
• Women who develop CC have one or more
identifiable factors that increase their risk
• Most studies are facility-based, need for population
based studies
2
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Specific objectives
• To determine the prevalence of cervical cancer risk
factors
• To determine the prevalence of precancerous
cervical changes
• To assess the knowledge of cervical cancer
• To identify the predictors of precancerous cervical
changes
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
3
Methods
• Study was in Lagos State in south-western Nigeria
• Consists of 3 Senatorial Districts and 20 LGAs
• Multi-ethnic city and commercial capital of Nigeria
• Estimated population-10 million (2006 census)
4
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Lagos city
5
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Geographical location of study area
Lagos
Nigeria
Source: Health Mapper; WHO GIS unit
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
6
Methods
• Study design: population based cross-sectional
study
• Study period: September-November 2012
• Sampling technique: five stage sampling
• Sample size: 332 participants
• Eligibility criteria: sexually active, non pregnant,
> 15 years with no previous diagnoses of cervical
cancer
7
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Data collection tool
• Interviewer administered semi structured questionnaire
–
–
–
–
socio-demographic characteristics
respondents’ knowledge of cervical cancer
preventive practices against cervical cancer
risk factors for cervical cancer in respondents
• Clinical assessment
– visual inspection with acetic acid (VIA) and visual inspection
with lugol’s iodine (VILI) of the cervix done for PCC
• PCC defined as both acetowhitening on VIA and
Yellowish changes on VILI
8
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Operational definitions of CC risk factors
• Early coitache: first sexual intercourse before 18 years
• Grandmultiparity: parity > 5
• Multiple sexual partner: lifetime partners > 4
• Sexually transmitted Infection: foul smelling and/or copious
vaginal discharge or a genital lesion
• Oral Contraceptive Pills (OCP) use: OCP use for at least 1 year
• Sexually active: at least one episode of sexual intercourse
• Multiple risks: 3 or more defined risk factors
. . . . Based on standard definitions, the National Demography and Health Survey
9
(NDHS) and literatures
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Grading of respondents’ knowledge
on cervical cancer
• Knowledge of respondents graded on a scale
• Eight items used for grading
• For each item
– Zero scored for wrong response
– One point for ‘’I don’t know ‘’response
– Two points for right response
• Maximum score was 16, minimum 0
– 12 to 16 points: Good knowledge
– 0 to 11 points: Poor knowledge
10
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Ethical considerations
• Ethical approval obtained from Nigeria Institute of
Medical Research (IRB/12/196)
• Informed consent obtained from respondents
• Respondents informed that positivity of VIA/VILI may not
imply a cervical cancer diagnoses, all with positive results
were referred for confirmation (colposcopy and biopsy)
and treatment
• Confidentiality was maintained
• Beneficence: All services were provided free
11
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Results
12
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Age distribution of respondents, Lagos;
September-November 2012
Age (in years)
Frequency
Proportion (%)
≤ 19
5
1.5
20-29
49
14.8
30-39
115
34.6
40-49
101
30.1
50-59
42
12.7
≥ 60
14
4.2
Missing
6
1.8
Total
332
100
13
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Age distribution of respondents, Lagos;
September-November 2012
Age (in years)
Frequency
Proportion (%)
≤ 19
5
1.5
20-29
49
14.8
30-39
115
34.6
40-49
101
30.1
50-59
42
12.7
≥ 60
14
4.2
Missing
6
1.8
Total
332
100
14
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Prevalence of risk factors of cervical cancer in
respondents, Lagos; Sept-Nov 2012
Variable
Frequency
percentage
Oral contraceptive use
140
44.3
Previous STI
76
24.1
Early coitache
67
20.2
Multiple sexual partners
45
14.6
Multiparity
36
13.4
Smoking
Multiple risks
4
34
1.3
10.2
15
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Prevalence of risk factors of cervical cancer in
respondents, Lagos; Sept-Nov 2012
Variable
Frequency
percentage
Oral contraceptive use
140
44.3
Previous STI
76
24.1
Early coitache
67
20.2
Multiple sexual partners
45
14.6
Multiparity
36
13.4
Smoking
Multiple risks
4
34
1.3
10.2
16
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Prevalence of risk factors of cervical cancer in
respondents, Lagos; Sept-Nov 2012
Variable
Frequency
percentage
Oral contraceptive use
140
44.3
Previous STI
76
24.1
Early coitache
67
20.2
Multiple sexual partners
45
14.6
Multiparity
36
13.4
Smoking
Multiple risks
4
34
1.3
10.2
17
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Prevalence of risk factors of cervical cancer in
respondents, Lagos; Sept-Nov 2012
Variable
Frequency
percentage
Oral contraceptive use
140
44.3
Previous STI
76
24.1
Early coitache
67
20.2
Multiple sexual partners
45
14.6
Multiparity
36
13.4
Smoking
Multiple risks
4
34
1.3
10.2
18
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Prevalence of risk factors of cervical cancer in
respondents, Lagos; Sept-Nov 2012
Variable
Frequency
percentage
Oral contraceptive use
140
44.3
Previous STI
76
24.1
Early coitache
67
20.2
Multiple sexual partners
45
14.6
Multiparity
36
13.4
Smoking
Multiple risks
4
34
1.3
10.2
19
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Prevalence of precancerous cervical changes
in respondents, Lagos; Sept-Nov 2012
100
90
Percentage
80
70
60
50
40
30
20
10
0
Precancerous cervical
changes
Normal
Finding on VIA/VILI
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
20
Prevalence of precancerous cervical changes
in respondents, Lagos; Sept-Nov 2012
100
87%
90
Percentage
80
70
60
50
40
30
20
13%
10
0
Precancerous cervical
changes
Normal
Finding on VIA/VILI
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
21
Awareness, screening utilization and
knowledge of CC; Sept-Nov, 2012
• Of 332 respondents
– 135 (41.9%) are aware of CC
– 11 (3.3%) had ever been screened for CC
• Of 135 respondents who are aware of CC
– 38 (28%) possess good knowledge on CC
– 49 (36.5%) have access to CC screening facility
22
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Factors associated with knowledge of cervical
cancer of respondents, Lagos; Sept-Nov, 2012
Factors
Educational level
No/Low
High
Age group
< 40 years
≥ 40 years
Marital status
Currently married
Not currently married
Good
knowledge
n (%)
Poor
knowledge
n(%)
Prevalence odd ratio
(95% CI)*
5 (14.7)
33 (41.8)
29(85.3)
46(58.2)
0.24 (0.08-0.68)
21 (27.3)
17 (43.6)
56 (72.3)
22 (57.4)
0.40 (0.22-1.09)
30 (37.0)
8 (21.6)
51 (63.0)
29 (67.9)
2.13 (0.86-5.26)
95% Confidence interval*
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
23
Factors associated with knowledge of cervical
cancer of respondents, Lagos; Sept-Nov, 2012
Factors
Educational level
No/Low
High
Age group
< 40 years
≥ 40 years
Marital status
Currently married
Not currently married
Good
knowledge
n (%)
Poor
knowledge
n(%)
Prevalence odd ratio
(95% CI)*
5 (14.7)
33 (41.8)
29(85.3)
46(58.2)
0.24 (0.08-0.68)
21 (27.3)
17 (43.6)
56 (72.3)
22 (57.4)
0.40 (0.22-1.09)
30 (37.0)
8 (21.6)
51 (63.0)
29 (67.9)
2.13 (0.86-5.26)
95% Confidence interval*
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
24
Factors associated with PCC among
respondents, Lagos; Sept-Nov, 2012
Factors
PCC
Yes
n (%)
No
n (%)
Prevalence odd
ratio ( 95% CI)*
P value
Multiple partners 25 (55.0)
20 (45.0)
18.7 (8.8- 39.8)
<0.001
Early coitache
30 (44.8)
37 (55.2)
15.7(7.5-32.8)
<0.001
Multiple risks
19(55.9)
15(44.1)
14.5 (6.5-32.0)
<0.001
Grandmultiparity
12(33.3)
24 (66.6)
4.3 (2.0-9.4)
0.001
OCP use
22(16.2)
114 (83.8)
1.4 (0.7-2.6)
0.461
8(11.8)
60(88.2)
0.8 (0.3-1.8)
0.686
Previous STI
95% Confidence interval*
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
25
Factors associated with PCC among
respondents, Lagos; Sept-Nov, 2012
Factors
PCC
Yes
n (%)
No
n (%)
Prevalence odd
ratio ( 95% CI)*
P value
Multiple partners 25 (55.0)
20 (45.0)
18.68 (8.76- 39.84) <0.001
Early coitache
30 (44.8)
37 (55.2)
15.72 (7.52-32.83)
<0.001
Multiple risks
19(55.9)
15(44.1)
14.46 (6.53-32.03)
<0.001
Grandmultiparity
12(33.3)
24 (66.6)
4.27 (1.95-9.39)
0.001
OCP use
22(16.2)
114 (83.8)
1.35 (0.70-2.59)
0.461
8(11.8)
60(88.2)
0.77 (0.34-1.77)
0.686
Previous STI
95% Confidence interval*
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
26
Factors associated with PCC among
respondents, Lagos; Sept-Nov, 2012
Factors
PCC
Yes
n (%)
No
n (%)
Prevalence odd
ratio ( 95% CI)*
P value
Multiple partners 25 (55.0)
20 (45.0)
18.68 (8.76- 39.84) <0.001
Early coitache
30 (44.8)
37 (55.2)
15.72 (7.52-32.83)
<0.001
Multiple risks
19(55.9)
15(44.1)
14.46 (6.53-32.03)
<0.001
Grandmultiparity
12(33.3)
24 (66.6)
4.27 (1.95-9.39)
0.001
OCP use
22(16.2)
114 (83.8)
1.35 (0.70-2.59)
0.461
8(11.8)
60(88.2)
0.77 (0.34-1.77)
0.686
Previous STI
95% Confidence interval*
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
27
Factors associated with PCC among
respondents, Lagos; Sept-Nov, 2012
Factors
PCC
Yes
n (%)
No
n (%)
Prevalence odd
ratio ( 95% CI)*
P value
Multiple partners 25 (55.0)
20 (45.0)
18.68 (8.76- 39.84) <0.001
Early coitache
30 (44.8)
37 (55.2)
15.72 (7.52-32.83)
<0.001
Multiple risks
19(55.9)
15(44.1)
14.46 (6.53-32.03)
<0.001
Grandmultiparity
12(33.3)
24 (66.6)
4.27 (1.95-9.39)
0.001
OCP use
22(16.2)
114 (83.8)
1.35 (0.70-2.59)
0.461
8(11.8)
60(88.2)
0.77 (0.34-1.77)
0.686
Previous STI
95% Confidence interval*
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
28
Factors associated with PCC among
respondents, Lagos; Sept-Nov, 2012
Factors
PCC
Yes
n (%)
No
n (%)
Prevalence odd
ratio ( 95% CI)*
P value
Multiple partners 25 (55.0)
20 (45.0)
18.68 (8.76- 39.84) <0.001
Early coitache
30 (44.8)
37 (55.2)
15.72 (7.52-32.83)
<0.001
Multiple risks
19(55.9)
15(44.1)
14.46 (6.53-32.03)
<0.001
Grandmultiparity
12(33.3)
24 (66.7)
4.27 (1.95-9.39)
0.001
OCP use
22(16.2)
114 (83.8)
1.35 (0.70-2.59)
0.461
8(11.8)
60(88.2)
0.77 (0.34-1.77)
0.686
Previous STI
95% Confidence interval*
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
29
Predictors of PCC on logistic regression
in respondents, Lagos; Sept-Nov, 2012
Variables
Adjusted
Odds ratio
95%
Confidence
interval
p value
Multiple sexual partners 9.69
3.29-28.50
<0.001
Early coitache
7.93
3.20-19.6
<0.001
Multiparity
1.67
0.57-4.85
0.35
Multiple risk factors
0.67
0.18-2.54
0.55
30
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Predictors of PCC on logistic regression
in respondents, Lagos; Sept-Nov, 2012
Variables
Adjusted
Odds ratio
95%
Confidence
interval
p value
Multiple sexual partners 9.69
3.29-28.50
<0.001
Early coitache
7.93
3.20-19.6
<0.001
Multiparity
1.67
0.57-4.85
0.35
Multiple risk factors
0.67
0.18-2.54
0.55
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
31
Discussion
• Most prevalent risk factors were modifiable factors
– oral contraceptive use
– previous STI
– early coitache
– multiparity
(Durowade et al, 2012, Oguntayo et al 2011 , Kahesa et al,
2012)
32
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Discussion
• High prevalence of PCC
(Daniel et al, 2013 (7%), Adekunle & Samaila, 2010
(4.8%)
• Factors independently associated with PCC
– multiple sexual partnering
– early coitache
33
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Discussion
• Knowledge significantly associated with educational
status
– Lindau et al in 2002 found literacy to be the only factor
independently associated with CC knowledge
• Very low cervical cancer screening uptake
‒ Ayinde and Omigbodun, Nigeria, 2002 (6.8%)
‒ Adanu in Ghana, 2002 (8.3%)
– Wellensiek and Moodley, South Africa, 2002 (36.7%)
34
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Limitations
• Social desirability bias- issues explored were sensitive
• Recall- issues majored on the long term memory of
respondents
• Inability to assess for Human papilloma virus infection
• Ascertainment bias- risk factors were self reported
• Sensitivity and specificity of VIA/VILI
35
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Conclusion
• High prevalence of
– risk factors of cervical cancer
– precancerous cervical changes
• Knowledge of cervical cancer was poor
• Cervical cancer screening utilization was low
• Predictors of PCC are modifiable factors
36
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Recommendations
• Efforts to boost cervical cancer screening through
improved understanding should be particularly
directed toward women with low education levels
• Health education on CC targeting women with
early coitache and multiple sexual partners was
initiated and needs to be sustained
37
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Acknowledgement
• This study was made possible by support from the
PEPFAR through cooperative agreement
[#5U2GGH000431] from CDC, Global AIDS
Program
• The findings and conclusions in this report are
those of the author(s) and do not necessarily
represent the official position of the CDC
38
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
THANK YOU !!!!
39
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Introduction
• Women who develop CC have one or more identifiable factors
(modifiable or non modifiable) that increase their risk
• Non modifiable factors
‒ Family history
‒ Age
‒ Race/ethnicity
• Modifiable factors
-sexual activity at an early age
-Multiple sexual partners
-Oral contraceptive use
-Cigarette smoking
-Multiparity
-Sexually transmitted infections (including Human Papilloma Virus
infection)
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
40
Sample size calculation
n=
z²pq
d²
Z= standard normal deviate corresponding to a 2 sided level of
significance=1.96
p= prevalence of CIN (Cervical Intraepithelial Neoplasia) in
Nigerian women (Audu et al, 1999) =18.3%= 0.183
d= level of precision=5%
q= 1-p=1-0.183=0.817
n = 253
Adjusting for a non response rate of 10%
41
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Recoding schema for study variables
Variable
Recoded variable
Age in years (Q 1)
< 20 years, 20-29 years, 30-39 years, 40-49 years,
50-59 years and >59 years
No education – No formal education
Highest level of education(Q5)
Marital status (Q3)
Low Education – Primary education
High Education– Secondary education & tertiary
education
Not currently married- single,
separated, divorced and widowed
cohabiting,
currently married- married
42
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Distribution of respondents by types of
preventive measures known
Preventive measure
Frequency
Percentage (%)
Pap smear
41
66.1
VIA/VILI
21
33.9
HPV DNA
0
0
HPV vaccine
0
0
Total
62
100
43
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Reported reasons for never being
screened for cervical cancer
Reasons
Frequency
Percentage
‘‘I don’t think it’s important’’
15
31.3
‘‘No screening facility is available’’
15
31.3
‘‘I am not a likely candidate for cervical
cancer’’
6
12.5
‘‘Screening is expensive ‘’
6
12.5
‘‘I am afraid it will hurt’’
3
6.3
‘‘I am afraid of the outcome’’
3
6.3
44
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Respondents’ sources of information on
cervical cancer, Lagos; Sept-Nov, 2012
100
89
Percentage
80
60
(n=135 for each source)
40
33
29
20
20
4
0
Mass
media(radio)
Health workers Church/Mosque Neighbour/friend Those with the
disease
Sources of information
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
45
Association between knowledge and having
ever screened for CC, Lagos; Sept-Nov, 2013
Knowledge
grade
Ever screened
Yes
No
Good
9 (40.9%)
12 (59.1%
Poor
2 (2.3%)
39 (97.7%)
Prevalence odd Fishers
ratio (95% CI)
exact
29.08 ( 3.4-35.5) < 0.001
46
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Data Processing and Analysis
• Double data entry undertaken
• Consistency checks performed to clean data
• Data analyzed with Epi-info software (version 3.5.1) and SPSS
Univariate analysis
– Frequencies and proportions
Bivariate analysis
– Identify associated factors
– Prevalence odd ratio used to determine statistical
significance
Unconditional logistic regression
– Control for effect modification and confounding
47
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Sampling technique
Multistage sampling
• Stages 1: 2 out of the 3 Senatorial Districts selected by
balloting.
• Stage 2: 2 LGAs also selected in each of the 2 selected
Senatorial Districts by balloting
• Stage 3: 1 ward was then selected in each of the 4
LGAs from the 2 senatorial districts by balloting
• Stage 4: Systematic random sampling was used to
select houses from the 4 selected wards.
• Stage 5: Sampling of one eligible female in all the
households in each selected house
48
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Association between non- modifiable
factors and PCC
PCC present
n (%)
PCC absent
n(%)
P value
Age group
< 40 years
23 (13.6)
145 (86.4)
≥ 40years
19 (12.1)
138 (87.9)
Yoruba
24 (12.4)
169 ( 87.6)
Others
19 (14.2)
115 ( 85.8)
0.81
Tribe
0.87
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
49
50
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Factors associated with awareness of cervical
cancer among respondents, Lagos; Sept-Nov, 2012
Factors
Aware of cervical cancer
Yes (n%)
Prevalence odd
ratio (95% CI)*
No (n%)
Educational level
No/Low
High
Age group
< 40 years
≥ 40 years
26 (21.7)
94 (66.7)
94 (78.3)
47 (33.3)
0.14 (0.08-0.24)
84 (50.6)
48 (32.0)
82 (49.4)
102 (68.0)
2.18 (1.38-3.44)
Marital status
Currently married
Not currently married
93 (42.3)
38 (41.3)
127 (57.7)
54 (58.7)
1.04 (0.64-1.71)
95% Confidence interval*
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
51
Predictors of cervical cancer awareness among
respondents, Lagos; Sept-Nov, 2012
Variables
Adjusted
Odds ratio
95%
Confidence
interval
p value
No/Low education
0.15
0.09-0.26
<0.001
> 40 years
1.59
0.91-2.77
0.1038
52
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Discussion
• Factors independently associated with PCC
– multiple sexual partnering
– early coitache
• Less than half of the study population were aware
of cervical cancer
–
Ogunbode and Ayinde, Nigeria, 2005 (40.8%)
– Adanu, Ghana, 2002 (93%)
• Media was the main source of information
• Knowledge of the disease was poor
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
53

similar documents