World Health Organization - Nigeria

BACKGROUND: The largest West African monkeypox outbreak began September 2017, in Nigeria. Four individuals traveling from Nigeria to the United Kingdom (n = 2), Israel (n = 1), and Singapore (n = 1) became the first human monkeypox cases exported from Africa, and a related nosocomial transmission event in the United Kingdom became the first confirmed human-to-human monkeypox transmission event outside of Africa. METHODS: Epidemiological and molecular data for exported and Nigerian cases were analyzed jointly to better understand the exportations in the temporal and geographic context of the outbreak. RESULTS: Isolates from all travelers and a Bayelsa case shared a most recent common ancestor and traveled to Bayelsa, Delta, or Rivers states. Genetic variation for this cluster was lower than would be expected from a random sampling of genomes from this outbreak, but data did not support direct links between travelers. CONCLUSIONS: Monophyly of exportation cases and the Bayelsa sample, along with the intermediate levels of genetic variation, suggest a small pool of related isolates is the likely source for the exported infections. This may be the result of the level of genetic variation present in monkeypox isolates circulating within the contiguous region of Bayelsa, Delta, and Rivers states, or another more restricted, yet unidentified source pool.

Health is central to the development of any country. Nigeria’s gross domestic product is the largest in Africa, but its per capita income of about ₦770 000 (US$2000) is low with a highly inequitable distribution of income, wealth, and therefore, health. It is a picture of poverty amidst plenty. Nigeria is both a wealthy country and a very poor one. About 40% of Nigerians live in poverty, in social conditions that create ill health, and with the ever-present risk of catastrophic expenditures from high out-of-pocket spending for health. Even compared with countries of similar income levels in Africa, Nigeria’s population health outcomes are poor, with national statistics masking drastic differences between rich and poor, urban and rural populations, and different regions.

BACKGROUND: The World Mental Health Surveys conducted by the World Health Organization (WHO) have shown that huge treatment gaps for severe mental disorders exist in both developed and developing countries. This gap is greatest in low and middle income countries (LMICs). Efforts to scale up mental health services in LMICs have to contend with the paucity of mental health professionals and health facilities providing specialist services for mental, neurological and substance use (MNS) disorders. A pragmatic solution is to improve access to care through the facilities that exist closest to the community, via a task-shifting strategy. This study describes a pilot implementation program to integrate mental health services into primary health care in Nigeria. METHODS: The program was implemented over 18 months in 8 selected local government areas (LGAs) in Osun state of Nigeria, using the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG), which had been contextualized for the local setting. A well supervised cascade training model was utilized, with Master Trainers providing training for the Facilitators, who in turn conducted several rounds of training for front-line primary health care workers. The first set of trainings by the Facilitators was supervised and mentored by the Master Trainers and refresher trainings were provided after 9 months. RESULTS: A total of 198 primary care workers, from 68 primary care clinics, drawn from 8 LGAs with a combined population of 966,714 were trained in the detection and management of four MNS conditions: moderate to severe major depression, psychosis, epilepsy, and alcohol use disorders, using the mhGAP-IG. Following training, there was a marked improvement in the knowledge and skills of the health workers and there was also a significant increase in the numbers of persons identified and treated for MNS disorders, and in the number of referrals. Even though substantial retention of gained knowledge was observed nine months after the initial training, some level of decay had occurred supporting the need for a refresher training. CONCLUSION: It is feasible to scale up mental health services in primary care settings in Nigeria, using the mhGAP-IG and a well-supervised cascade-training model. This format of training is pragmatic, cost-effective and holds promise, especially in settings where there are few specialists.

In 1998, the WHO African region adopted a strategy called Integrated Disease Surveillance and Response (IDSR). Here, we present the current status of IDSR implementation; and provide some future perspectives for enhancing the IDSR strategy in Africa. In 2017, we used two data sources to compile information on the status of IDSR implementation: a pretested rapid assessment questionnaire sent out biannually to all countries and quarterly compilation of data for two IDSR key performance indicators (KPI). The first KPI measures country IDSR performance and the second KPI tracks the number of countries that the WHO secretariat supports to scale up IDSR. The KPI data for 2017 were compared with a retrospective baseline for 2014. By December 2017, 44 of 47 African countries (94%) were implementing IDSR. Of the 44 countries implementing IDSR, 40 (85%) had initiated IDSR training at subnational level; 32 (68%) had commenced community-based surveillance; 35 (74%) had event-based surveillance; 33 (70%) had electronic IDSR; and 32 (68%) had a weekly/monthly bulletin for sharing IDSR data. Thirty-two countries (68%) had achieved the timeliness and completeness threshold of at least 80% of the reporting units. However, only 12 countries (26%) had the desired target of at least 90% IDSR implementation coverage at the peripheral level. After 20 years of implementing IDSR, there are major achievements in the indicator-based surveillance systems. However, major gaps were identified in event-based surveillance. All African countries should enhance IDSR everywhere.

Since 2005, a large poliomyelitis outbreak associated with type 2 circulating vaccine-derived poliovirus (cVDPV2) has occurred in northern Nigeria, where immunization coverage with trivalent oral poliovirus vaccine (tOPV) has been low. Phylogenetic analysis of P1/capsid region sequences of isolates from each of the 403 cases reported in 2005 to 2011 resolved the outbreak into 23 independent type 2 vaccine-derived poliovirus (VDPV2) emergences, at least 7 of which established circulating lineage groups. Virus from one emergence (lineage group 2005-8; 361 isolates) was estimated to have circulated for over 6 years. The population of the major cVDPV2 lineage group expanded rapidly in early 2009, fell sharply after two tOPV rounds in mid-2009, and gradually expanded again through 2011. The two major determinants of attenuation of the Sabin 2 oral poliovirus vaccine strain (A481 in the 5'-untranslated region [5'-UTR] and VP1-Ile143) had been replaced in all VDPV2 isolates; most A481 5'-UTR replacements occurred by recombination with other enteroviruses. cVDPV2 isolates representing different lineage groups had biological properties indistinguishable from those of wild polioviruses, including efficient growth in neuron-derived HEK293 cells, the capacity to cause paralytic disease in both humans and PVR-Tg21 transgenic mice, loss of the temperature-sensitive phenotype, and the capacity for sustained person-to-person transmission. We estimate from the poliomyelitis case count and the paralytic case-to-infection ratio for type 2 wild poliovirus infections that ∼700,000 cVDPV2 infections have occurred during the outbreak. The detection of multiple concurrent cVDPV2 outbreaks in northern Nigeria highlights the risks of cVDPV emergence accompanying tOPV use at low rates of coverage in developing countries.

Improved understanding of the current burden of hypertension, including awareness, treatment, and control, is needed to guide relevant preventative measures in Nigeria. A systematic search of studies on the epidemiology of hypertension in Nigeria, published on or after January 1990, was conducted. The authors employed random-effects meta-analysis on extracted crude hypertension prevalence, and awareness, treatment, and control rates. Using a meta-regression model, overall hypertension cases in Nigeria in 1995 and 2020 were estimated. Fifty-three studies (n = 78 949) met our selection criteria. Estimated crude prevalence of pre-hypertension (120-139/80-89 mmHg) in Nigeria was 30.9% (95% confidence interval [CI]: 22.0%-39.7%), and the crude prevalence of hypertension (≥140/90 mmHg) was 30.6% (95% CI: 27.3%-34.0%). When adjusted for age, study period, and sample, absolute cases of hypertension increased by 540% among individuals aged ≥20 years from approximately 4.3 million individuals in 1995 (age-adjusted prevalence 8.6%, 95% CI: 6.5-10.7) to 27.5 million individuals with hypertension in 2020 (age-adjusted prevalence 32.5%, 95% CI: 29.8-35.3). The age-adjusted prevalence was only significantly higher among men in 1995, with the gap between both sexes considerably narrowed in 2020. Only 29.0% of cases (95% CI: 19.7-38.3) were aware of their hypertension, 12.0% (95% CI: 2.7-21.2) were on treatment, and 2.8% (95% CI: 0.1-5.7) had at-goal blood pressure in 2020. Our study suggests that hypertension prevalence has substantially increased in Nigeria over the last two decades. Although more persons are aware of their hypertension status, clinical treatment and control rates, however, remain low. These estimates are relevant for clinical care, population, and policy response in Nigeria and across Africa.

OBJECTIVE: We examine socio-economic status (SES) and geographic differences in willingness of respondents to pay for community-based health insurance (CBHI). METHODS: The study took place in Anambra and Enugu states, south-east Nigeria. It involved a rural, an urban and a semi-urban community in each of the two states. A pre-tested interviewer-administered questionnaire was used to collect information from a total of 3070 households selected by simple random sampling. Contingent valuation was used to elicit willingness to pay (WTP) using the bidding game format. Data were examined for correlation between SES and geographic locations with WTP. Log ordinary least squares (OLS) was used to examine the construct validity of elicited WTP. RESULTS: Generally, less than 40% of the respondents were willing to pay for CBHI membership for themselves or other household members. The proportions of people who were willing to pay were much lower in the rural communities, at less than 7%. The average that respondents were willing to pay as a monthly premium for themselves ranged from 250 Naira (US$1.7) in a rural community to 343 Naira (US$2.9) in an urban community. The higher the SES group, the higher the stated WTP amount. Similarly, the urbanites stated higher WTP compared with peri-urban and rural dwellers. Males and people with more education stated higher WTP values than females and those with less education. Log OLS also showed that previously paying out-of-pocket for health care was negatively related to WTP. Previously paying for health care using any health insurance mechanism was positively related to WTP. CONCLUSION: Economic status and place of residence amongst other factors matter in peoples' WTP for CBHI membership. Consumer awareness has to be created about the benefits of CBHI, especially in rural areas, and the amount to be paid has to be augmented with other means of financing (e.g. government and/or donor subsidies) to ensure success and sustainability of CBHI schemes.

The novel coronavirus disease 2019, COVID-19, which is caused by severe acute respiratory syndrome
\nvirus 2 (SARS-CoV-2) [1] was first reported in December 2019 by Chinese Health Authorities following an outbreak of pneumonia of unknown origin in Wuhan, Hubei Province [2,3]. SARS-CoV-2 is
\nlikely of zoonotic origin, similar to SARS and Middle East Respiratory Syndrome (MERS), and transmitted between humans through respiratory droplets and fomites. Since its emergence, it has rapidly
\nspread globally [4].

During an outbreak of yellow fever (YF) in Nigeria in 1986-1987, women at various stages of pregnancy were vaccinated against YF, either because those pregnancies were not known at the time or because they requested vaccination out of fear of acquiring the disease. This offered an opportunity to assess the safety and efficacy of YF vaccine in pregnant women and the effect of this vaccine on their newborn children. Pre-vaccination and post-vaccination serum samples from the vaccinated pregnant women were tested by enzyme-linked immunosorbent assay and by neutralization tests for antibody to YF virus. The results showed that the antibody responses of these pregnant women were much lower than those of YF-vaccinated, non-pregnant women in a comparable control group. Follow-up of these women and their newborn children for 3-4 years showed no abnormal effect that could be attributed to the YF vaccine, which suggests that vaccination of pregnant women, particularly during a YF epidemic, may not be contraindicated.

BACKGROUND: The largest recorded outbreak of a circulating vaccine-derived poliovirus (cVDPV), detected in Nigeria, provides a unique opportunity to analyze the pathogenicity of the virus, the clinical severity of the disease, and the effectiveness of control measures for cVDPVs as compared with wild-type poliovirus (WPV). METHODS: We identified cases of acute flaccid paralysis associated with fecal excretion of type 2 cVDPV, type 1 WPV, or type 3 WPV reported in Nigeria through routine surveillance from January 1, 2005, through June 30, 2009. The clinical characteristics of these cases, the clinical attack rates for each virus, and the effectiveness of oral polio vaccines in preventing paralysis from each virus were compared. RESULTS: No significant differences were found in the clinical severity of paralysis among the 278 cases of type 2 cVDPV, the 2323 cases of type 1 WPV, and the 1059 cases of type 3 WPV. The estimated average annual clinical attack rates of type 1 WPV, type 2 cVDPV, and type 3 WPV per 100,000 susceptible children under 5 years of age were 6.8 (95% confidence interval [CI], 5.9 to 7.7), 2.7 (95% CI, 1.9 to 3.6), and 4.0 (95% CI, 3.4 to 4.7), respectively. The estimated effectiveness of trivalent oral polio vaccine against paralysis from type 2 cVDPV was 38% (95% CI, 15 to 54%) per dose, which was substantially higher than that against paralysis from type 1 WPV (13%; 95% CI, 8 to 18%), or type 3 WPV (20%; 95% CI, 12 to 26%). The more frequent use of serotype 1 and serotype 3 monovalent oral polio vaccines has resulted in improvements in vaccine-induced population immunity against these serotypes and in declines in immunity to type 2 cVDPV. CONCLUSIONS: The attack rate and severity of disease associated with the recent cVDPV identified in Nigeria are similar to those associated with WPV. International planning for the management of the risk of WPV, both before and after eradication, must include scenarios in which equally virulent and pathogenic cVDPVs could emerge.

BACKGROUND: The migration of healthcare workers (HWs) from low/middle-income countries (LMICs) is a pressing global health issue with implications for population-level health outcomes. We aimed to synthesise the drivers of HWs' out-migration, intention to migrate and non-migration from LMICs. METHODS: We searched Ovid MEDLINE, EMBASE, CINAHL, Global Health and Web of Science, as well as the reference lists of retrieved articles. We included studies (quantitative, qualitative or mixed-methods) on HWs' migration or intention to migrate, published in either English or French between 1 January 1970 and 31 August 2022. The retrieved titles were deduplicated in EndNote before being exported to Rayyan for independent screening by three reviewers. RESULTS: We screened 21 593 unique records and included 107 studies. Of the included studies, 82 were single-country studies focusing on 26 countries, while the remaining 25 included data from multiple LMICs. Most of the articles focused on either doctors 64.5% (69 of 107) and/or nurses 54.2% (58 of 107). The UK (44.9% (48 of 107)) and the USA (42% (45 of 107)) were the top destination countries. The LMICs with the highest number of studies were South Africa (15.9% (17 of 107)), India (12.1% (13 of 107)) and the Philippines (6.5% (7 of 107)). The major drivers of migration were macro-level and meso-level factors. Remuneration (83.2%) and security problems (58.9%) were the key macro-level factors driving HWs' migration/intention to migrate. In comparison, career prospects (81.3%), good working environment (63.6%) and job satisfaction (57.9%) were the major meso-level drivers. These key drivers have remained relatively constant over the last five decades and did not differ among HWs who have migrated and those with intention to migrate or across geographical regions. CONCLUSION: Growing evidence suggests that the key drivers of HWs' migration or intention to migrate are similar across geographical regions in LMICs. Opportunities exist to build collaborations to develop and implement strategies to halt this pressing global health problem.

Despite impressive progress in the fight against malnutrition and hunger in recent years, food and nutrition insecurity remains a major concern in Sub-Saharan Africa (SSA) countries. In this study, we employ a panel data covering 15 SSA countries from 1996 to 2015 to investigate the growth effects of remittances and quality of governance on food and nutrition security, proxied by the average value of food production and the average dietary energy supply adequacy, respectively. We use a dynamic empirical model based on system GMM to control for unobserved heterogeneity and potential endogeneity of the explanatory variables. The empirical results emanating from our analysis show that the interaction of remittances and the composite index of governance quality exerts positive and significant effects on the average value of food production, and also contributes to the improvement of average dietary energy supply adequacy in SSA. In addition, the control of corruption, government effectiveness, political stability and rule of law scores increase both measures of food and nutrition security. Albeit, the contribution of control over corruption score is relatively the largest as compared to other indicators of governance.

Wild poliovirus has remained endemic in northern Nigeria because of low coverage achieved in the routine immunization program and in supplementary immunization activities (SIAs). An outbreak of infection involving 315 cases of type 2 circulating vaccine-derived poliovirus (cVDPV2; >1% divergent from Sabin 2) occurred during July 2005-June 2010, a period when 23 of 34 SIAs used monovalent or bivalent oral poliovirus vaccine (OPV) lacking Sabin 2. In addition, 21 "pre-VDPV2" (0.5%-1.0% divergent) cases occurred during this period. Both cVDPV and pre-VDPV cases were clinically indistinguishable from cases due to wild poliovirus. The monthly incidence of cases increased sharply in early 2009, as more children aged without trivalent OPV SIAs. Cumulative state incidence of pre-VDPV2/cVDPV2 was correlated with low childhood immunization against poliovirus type 2 assessed by various means. Strengthened routine immunization programs in countries with suboptimal coverage and balanced use of OPV formulations in SIAs are necessary to minimize risks of VDPV emergence and circulation.

International air travel has already spread Ebola virus disease (EVD) to major cities as part of the unprecedented epidemic that started in Guinea in December 2013. An infected airline passenger arrived in Nigeria on July 20, 2014 and caused an outbreak in Lagos and then Port Harcourt. After a total of 20 reported cases, including 8 deaths, Nigeria was declared EVD free on October 20, 2014. We quantified the impact of early control measures in preventing further spread of EVD in Nigeria and calculated the risk that a single undetected case will cause a new outbreak. We fitted an EVD transmission model to data from the outbreak in Nigeria and estimated the reproduction number of the index case at 9.0 (95% confidence interval [CI]: 5.2-15.6). We also found that the net reproduction number fell below unity 15 days (95% CI: 11-21 days) after the arrival of the index case. Hence, our study illustrates the time window for successful containment of EVD outbreaks caused by infected air travelers.

The recent outbreak of Ebola Virus Disease (EVD) in West Africa has ravaged many lives. Effective containment of this outbreak relies on prompt and effective coordination and communication across various interventions; early detection and response being critical to successful control. The use of information and communications technology (ICT) in active surveillance has proved to be effective but its use in Ebola outbreak response has been limited. Due to the need for timeliness in reporting and communication for early discovery of new EVD cases and promptness in response; it became imperative to empower the response team members with technologies and solutions which would enable smooth and rapid data flow. The Open Data Kit and Form Hub technology were used in combination with the Dashboard technology and ArcGIS mapping for follow up of contacts, identification of cases, case investigation and management and also for strategic planning during the response. A remarkable improvement was recorded in the reporting of daily follow-up of contacts after the deployment of the integrated real time technology. The turnaround time between identification of symptomatic contacts and evacuation to the isolation facility and also for receipt of laboratory results was reduced and informed decisions could be taken by all concerned. Accountability in contact tracing was ensured by the use of a GPS enabled device. The use of innovative technologies in the response of the EVD outbreak in Nigeria contributed significantly to the prompt control of the outbreak and containment of the disease by providing a valuable platform for early warning and guiding early actions.

BACKGROUND: Mortality from road traffic injuries in sub-Saharan Africa is among the highest in the world, yet data from the region are sparse. To date, no multi-site population-based survey on road traffic injuries has been reported from Nigeria, the most populated country in Africa. OBJECTIVE: To explore the epidemiology of road traffic injury in Nigeria and provide data on the populations affected and risk factors for road traffic injury. DESIGN: Data from a population-based survey using two-stage stratified cluster sampling. SUBJECTS/ SETTING: Road traffic injury status and demographic information were collected on 3082 respondents living in 553 households in seven of Nigeria's 37 states. MAIN OUTCOME MEASURES: Incidence rates were estimated with confidence intervals based on a Poisson distribution; Poisson regression analysis was used to calculate relative risks for associated factors. RESULTS: The overall road traffic injury rate was 41 per 1000 population (95% CI 34 to 49), and mortality from road traffic injuries was 1.6 per 1000 population (95% CI 0.5 to 3.8). Motorcycle crashes accounted for 54% of all road traffic injuries. The road traffic injury rates found for rural and urban respondents were not significantly different. Increased risk of injury was associated with male gender among those aged 18-44 years, with a relative risk of 2.96 when compared with women in the same age range (95% CI 1.72 to 5.09, p<0.001). CONCLUSIONS: The road traffic injury rates found in this survey highlight a neglected public health problem in Nigeria. Simple extrapolations from this survey suggest that over 4 million people may be injured and as many as 200 000 potentially killed as the result of road traffic crashes annually in Nigeria. Appropriate interventions in both the health and transport sectors are needed to address this significant cause of morbidity and mortality in Nigeria.

Newcastle disease (ND) is an OIE listed disease caused by virulent avian paramyxovirus type 1 (APMV-1) strains, which affect many species of birds and may cause severe economic losses in the poultry sector. The disease has been officially and unofficially reported in many African countries and still remains the main poultry disease in commercial and rural chickens of Africa. Unfortunately, virological and epidemiological information concerning ND strains circulating in the Western and Central regions of Africa is extremely scarce. In the present study, sequence analysis, pathotyping and detailed genetic characterization of virulent ND strains detected in rural poultry in West and Central Africa revealed the circulation of a new genetic lineage, distinguishable from the lineages described in the Eastern and Southern parts of the continent. Several mismatches were observed in the segment of the matrix gene targeted by the primers and probe designed for the molecular detection of APMV-1, which were responsible for the false negative results in the diagnostic test conducted. Furthermore, deduced amino acid sequences of the two major antigens eliciting a protective immune response (F and HN glycoprotein) revealed protein similarities <90% if compared to some common vaccine strains. Distinct mutations located in the neutralizing epitopes were revealed, indicating the need for detailed assessment of the efficacy of the current vaccines and vaccination practices in Africa. The present investigation provides important information on the epidemiology, diagnosis and control of NDV in Africa and highlights the importance of supporting surveillance in developing countries for transboundary animal diseases.

Background Targeted public health response to obesity in Nigeria is relatively low due to limited epidemiologic understanding. We aimed to estimate nationwide and sub-national prevalence of overweight and obesity in the adult Nigerian population.Methods MEDLINE, EMBASE, Global Health, and Africa Journals Online were systematically searched for relevant epidemiologic studies in Nigeria published on or after 01 January 1990. We assessed quality of studies and conducted a random-effects meta-analysis on extracted crude prevalence rates. Using a meta-regression model, we estimated the number of overweight and obese persons in Nigeria in the year 2020.Results From 35 studies (n = 52,816), the pooled crude prevalence rates of overweight and obesity in Nigeria were 25.0% (95% confidence interval, CI: 20.4–29.6) and 14.3% (95% CI: 12.0–15.5), respectively. The prevalence in women was higher compared to men at 25.5% (95% CI: 17.1–34.0) versus 25.2% (95% CI: 18.0–32.4) for overweight, and 19.8% (95% CI: 3.9–25.6) versus 12.9% (95% CI: 9.1–16.7) for obesity, respectively. The pooled mean body mass index (BMI) and waist circumference were 25.6 kg/m2 and 86.5 cm, respectively. We estimated that there were 21 million and 12 million overweight and obese persons in the Nigerian population aged 15 years or more in 2020, accounting for an age-adjusted prevalence of 20.3% and 11.6%, respectively. The prevalence rates of overweight and obesity were consistently higher among urban dwellers (27.2% and 14.4%) compared to rural dwellers (16.4% and 12.1%).Conclusions Our findings suggest a high prevalence of overweight and obesity in Nigeria. This is marked in urban Nigeria and among women, which may in part be due to widespread sedentary lifestyles and a surge in processed food outlets, largely reflective of a trend across many African settings.KEY MESSAGESAbout 12 million persons in Nigeria were estimated to be obese in 2020, with prevalence considerably higher among women. Nutritional and epidemiological transitions driven by demographic changes, rising income, urbanization, unhealthy lifestyles, and consumption of highly processed diets appear to be driving an obesity epidemic in the country.

&lt;p&gt;Country Contextualization of the Mental Health Gap Action Programme Intervention Guide: A Case Study from Nigeria&lt;/p&gt;

Background: Access to safe, effective, affordable, and quality medicines is an essential component of the right to health and is also one of the targets in the global development agenda. In this review article, we extensively discuss the challenges and issues surrounding access to medicines in the African region as well as provides recommendations for ensuring medicines security on the continent. Methods: We conducted narrative review with the use of data reported in published literature, reports, and grey literature available in African countries on topics pertaining access to medicines. The authors also snowballed further data to gather information for this review and narrative synthesis was conducted. Results: Africa faces a double burden of infectious and non-communicable diseases and the need for effective universal access to medicines cannot be deemphasized. However, access to medicines on the continent is not without issues and challenges. Some of which are the high burden of infectious diseases and non-infectious diseases, limited pharmaceutical industries and high costs of raw materials, overdependence on countries abroad for medicines, poor supply chain systems, lack of government investment in the pharmaceutical sector, unfavourable manufacturing conditions, limited health workforce, lack of sustainable health financing mechanisms, lack of infrastructures and technical know-how, low investment on research and development, and circulation of fake and counterfeit medicines among others. Conclusion: This review reifies that access to medicines in Africa faces numerous challenges and it emphasizes the urgent need to address these issues as the continent geared towards strengthening its health systems for universal health coverage.