Ari Ho-Foster

Cervical Cancer in Botswana: Current State and Future Steps for Screening and Treatment Programs.

Botswana has a high burden of cervical cancer due to a limited screening program and high HIV prevalence. About 60% of the cervical cancer patients are HIV positive; most present with advanced cervical disease. Through initiatives by the Botswana Ministry of Health and various strategic partnerships, strides have been made in treatment of pre-invasive and invasive cancer. The See and Treat program for cervical cancer is expanding throughout the country. Starting in 2015, school-going girls will be vaccinated against HPV. In regards to treatment of invasive cancer, a multidisciplinary clinic has been initiated at the main oncology hospital to streamline care. However, challenges remain such as delays in treatment, lack of trained human personnel, limited follow-up care, and little patient education. Despite improvements in the care of pre-invasive and invasive cervical cancer patients, for declines in cervical cancer-related morbidity and mortality to be achieved, Botswana needs to continue to invest in decreasing the burden of disease and improving patient outcomes of patients with cervical cancer.

Yield of contact tracing from pediatric tuberculosis index cases in Gaborone, Botswana.

SETTING Contact tracing using pediatric index cases has not been adequately investigated in high tuberculosis (TB) and human immunodeficiency virus (HIV) prevalence settings. OBJECTIVE To determine the yield of contact tracing in household contacts of pediatric TB index cases in Botswana. DESIGN Index cases included all pediatric (age ≤ 13 years) TB admissions from January 2009 to December 2011 to Botswanas largest referral hospital. A contact tracing team identified cases, conducted home visits, symptom-screened contacts and referred those with ≥ 1 TB symptoms. The primary outcome was newly diagnosed TB in a contact. RESULTS From 163 pediatric index cases, 548 contacts were screened (median 3 contacts/case, interquartile range [IQR] 2-4). Of these, 49 (9%) were referred for positive symptoms on screening and 27/49 (55%) were evaluated for active TB. Twelve new TB cases were diagnosed (12/548, 2.2%); the median age was 31 years (IQR 23-38); 11 (92%) were smear-positive. Ten (83%) had known HIV status: 7 (70%) were HIV-positive. To find one new TB case, the number needed to contact trace (index cases/new cases) was 13.6, and the number needed to screen (contacts/new cases) was 46. CONCLUSION This yield of contact tracing using pediatric index cases is similar to the traditional adult index case approach. Improving the proportion of symptomatic contacts evaluated may increase yield.

Leveraging HIV Programming to Enhance Access to Noncommunicable Disease Care in Southern Botswana.

Objective: The objective of this study was to assess whether HIV programming in southern Botswana could be leveraged to provide care for patients with noncommunicable diseases (NCDs). Methods: A retrospective analysis was performed to determine the spectrum and complexity of NCDs seen by HIV-focused outreach programming delivered between July 2011 and December 2013, to 9 facilities in southern Botswana. The association of HIV status and specific International Classification of Disease codes was examined using bivariate analysis. Results: Outreach HIV physicians recorded 926 outpatient consults involving 835 patients during the studied period. While 25% (n = 209) of patients seen were HIV infected, most patients were either HIV negative (49%, n = 410) or had an unknown HIV status (26%, n = 216). Noncommunicable disease referrals were as common at primary- and district-level facilities (90% [n = 459] versus 93% [n = 301]; P = .22). Conclusion: This study demonstrates how HIV programming in Botswana can be leveraged to improve access to specialist medical services for patients with NCDs.

Evaluation of a Mobile Health Approach to Tuberculosis Contact Tracing in Botswana

Tuberculosis (TB) contact tracing is typically conducted in resource-limited settings with paper forms, but this approach may be limited by inefficiencies in data collection, storage, and retrieval and poor data quality. In Botswana, we developed, piloted, and evaluated a mobile health (mHealth) approach to TB contact tracing that replaced the paper form–based approach for a period of six months. For both approaches, we compared the time required to complete TB contact tracing and the quality of data collected. For the mHealth approach, we also administered the Computer System Usability Questionnaire to 2 health care workers who used the new approach, and we identified and addressed operational considerations for implementation. Compared to the paper form–based approach, the mHealth approach reduced the median time required to complete TB contact tracing and improved data quality. The mHealth approach also had favorable overall rating, system usefulness, information quality, and interface quality scores on the Computer System Usability Questionnaire. Overall, the mHealth approach to TB contact tracing improved on the paper form–based approach used in Botswana. This new approach may similarly benefit TB contact tracing efforts in other resource-limited settings.

Diagnosis of paediatric tuberculosis using sputum induction in Botswana: programme description and findings.

SETTING Four public hospitals in Botswana, a high tuberculosis (TB) burden setting. OBJECTIVES To assess the feasibility and utility of sputum induction in the diagnosis of paediatric TB. DESIGN From 2008 to 2010, children aged ≤18 years referred for suspected pulmonary TB underwent sputum induction. Confirmed TB was defined as the presence of at least one of the signs and symptoms suggestive of TB and positive Mycobacterium tuberculosis culture. Information on TB-associated symptoms (cough, fatigue, night sweats, low appetite, chest pain, weight loss, haemoptysis and contact with a TB case) was collected for three risk groups: human immunodeficiency virus (HIV) positive children, HIV-negative children aged <3 years and HIV-negative children aged ≥3 years. RESULTS The median age of the 1394 subjects who underwent sputum induction was 3.8 years (IQR 1.3-8.4); 373 (27%) were HIV-positive, 419 (30%) were HIV-negative and 602 (43%) had unknown HIV status. TB was confirmed in 84 (6.0%); cases were more likely to have weight loss, chest pain or TB household contacts. There were no serious complications attributable to sputum induction during and after the procedure; only 0.8% (9/1174) of patients reported minor complications. CONCLUSIONS In Botswana, paediatric sputum induction was feasible, safe and assisted bacteriological confirmation in a subgroup of children treated for TB.

Information needs of Botswana health care workers and perceptions of wikipedia

BACKGROUND Since the UN Human Rights Councils recognition on the subject in 2011, the right to access the Internet and information is now considered one of the most basic human rights of global citizens [1,2]. Despite this, an information gap between developed and resource-limited countries remains, and there is scant research on actual information needs of workers themselves. The Republic of Botswana represents a fertile ground to address existing gaps in research, policy, and practice, due to its demonstrated gap in access to information and specialists among rural health care workers (HCWs), burgeoning mHealth capacity, and a timely offer from Orange Telecommunications to access Wikipedia for free on mobile platforms for Botswana subscribers. OBJECTIVES In this study, we sought to identify clinical information needs of HCWs of Botswana and their perception of Wikipedia as a clinical tool. METHODS Twenty-eight facilitated focus groups, consisting of 113 HCWs of various cadres based at district hospitals, clinics, and health posts around Botswana, were employed. Transcription and thematic analysis were performed for those groups. RESULTS Access to the Internet is limited at most facilities. Most HCWs placed high importance upon using Botswana Ministry of Health (MoH) resources for obtaining credible clinical information. However, the clinical applicability of these materials was limited due to discrepancies amongst sources, potentially outdated information, and poor optimization for time-sensitive circumstances. As a result, HCWs faced challenges, such as loss of patient trust and compromises in patient care. Potential solutions posed by HCWs to address these issues included: multifaceted improvements in Internet infrastructure, access to up-to-date information, transfer of knowledge from MoH to HCW, and improving content and applicability of currently available information. Topics of clinical information needs were broad and encompassed: HIV, TB (Tuberculosis), OB/GYN (Obstetrics and Gynecology), and Pediatrics. HCW attitudes towards Wikipedia were variable; some trusted Wikipedia as a reliable point of care information resource whereas others thought that its use should be restricted and monitored by the MoH. CONCLUSIONS There is a demonstrated need for accessible, reliable, and up-to-date information to aid clinical practice in Botswana. Attitudes towards Wikipedia as an open information resource tool are at best, split. Therefore, future studies are necessary to determine the accuracy, currency, and relevancy of Wikipedia articles on the health topics identified by health care workers as areas of information need. More broadly speaking, future efforts should be dedicated to configure a quality-controlled, readily accessible mobile platform based clinical information application tool fitting for Botswana.

Screening for tuberculosis in a diabetes clinic in Gaborone, Botswana.

The tuberculosis (TB) case notification rate in Botswana is one of the highest in Africa.1 While more than 63% of cases occur in individuals infected with the human immunodeficiency virus (HIV),1 there is growing concern that diabetes mellitus (DM) may characterize another under-recognized high risk group in this setting.2,3 Research from high-income settings has demonstrated that DM patients are at increased risk of TB.3 However, there are no data describing the burden of TB disease among patients with DM in Botswana, despite the fact that approximately 10% of Batswana have DM.4 We sought to determine the burden of TB disease in the main DM clinic in Gaborone, Botswana. After providing consent, eligible patients attending the clinic were enrolled and screened for TB symptoms (cough .2 weeks, fever, night sweats, and weight loss); those screening positive for one or more symptom were then sent for sputum smear microscopy and chest radiograph (CXR) in accordance with national guidelines. The study was approved by Institutional Review Boards of Botswana’s Ministry of Health, University of Botswana and University of Pennsylvania. Of 823 DM patients routinely screened between 5 August and 6 September 2013, 47 (5.7%) had one or more TB symptoms. Of the 177 enrolled in the study, 43 screened positive, while 134 were asymptomatic for TB. Sputum samples were collected from 30% (n 1⁄4 14) of those individuals screening positive; CXR was performed on 28% (n 1⁄4 13). We found no difference in HIV infection rates between those with and those without TB symptoms (13% [6/43] vs. 10% [14/134], P 1⁄4 0.53), nor were there significant differences in the proportion with a history of TB (12% [5/43] vs. 8% [11/134], P1⁄4 0.50). No patients enrolled in the study were diagnosed with TB. Despite the very high reported case notification rates in Botswana,1 we detected zero cases of TB. While this might suggest that TB need not be a public health concern in Botswana’s DM clinics, we argue that the data tell another story. Notably, CXR and smear microscopy were performed on a small fraction of those who screened positive. A lack of on-site diagnostic resources was partly responsible for such low numbers; participants had to travel to other clinics to undergo CXRs. However, even if more of those screening positive had undergone testing for TB, the data may have underestimated TB incidence among DM patients, as only about 20% of individuals with DM in Botswana know their DM diagnosis.4 It is not surprising that we did not see any cases of TB among the HIV-infected patients, given the small sample size and the fact that the HIV-infected patients attending the DM clinic were almost all on antiretroviral treatment. We acknowledge the limitations of our study: we only performed diagnostic tests on those individuals who screened positive and we only analyzed data over a short period of time. While the data do not suggest that TB is a problem among DM patients in Gaborone, this is not consistent with data from elsewhere in Africa.5 More research is warranted to investigate how the increasing incidence of DM impacts TB control efforts in Botswana.

Tuberculosis among individuals with community-acquired pneumonia presenting to emergency in Gaborone, Botswana.

Delays in diagnosing Tuberculosis (TB) are associated with increased transmission. TB may present as a clinical syndrome that mimics community-acquired pneumonia (CAP). The aim of this paper was to determine frequency of TB among patients with CAP at a referral hospital in Gaborone, Botswana. We performed a retrospective study of adults presenting with CAP from April 2010-October 2011 to the Emergency Department (ED); we matched this cohort to the National Botswana Tuberculosis Registry (NBTR) to identify individuals subsequently diagnosed with TB. We assessed demographics, time to TB diagnosis, clinical outcomes and performed logistic regressions to identify factors associated with TB diagnosis. We identified 1305 individuals presenting with CAP; TB was subsequently diagnosed in 68 (5.2%). The median time to TB diagnosis was 9.5 days. Forty percent were AFB sputum smear positive and 87% were identified as being HIV-positive. Subsequent diagnosis of TB is common among individuals with CAP at our ED, suggesting that TB may be present at the time of CAP presentation. Given the lack of distinguishing clinical factors between pulmonary TB and CAP, adults presenting with CAP should be evaluated for active TB in Botswana.

Risk factors for gastric aspirate culture contamination in children evaluated for tuberculosis in Botswana

SETTING Gastric aspirate (GA) sample culture is commonly performed in children evaluated for tuberculosis (TB) who cannot expectorate sputum. Contamination limits culture yield and negatively impacts care. OBJECTIVE To evaluate the proportion of and factors associated with GA contamination at a central TB reference laboratory in Botswana. DESIGN This was a 5-year cross-sectional study of untreated children aged 12 years evaluated for TB with the first GA sample registered at the National Tuberculosis Reference Laboratory. We performed descriptive statistics to assess the risk of contamination with patient age, sex, transport time and distance, culture medium, and facility type. We generated multivariable logistic regression models using generalized estimating equation extension. RESULTS We analyzed 3642 samples. The median age was 2 years (interquartile range [IQR] 1-4), median transport time was 4 days (IQR 2-7), and 64.1% of samples were from clinics or health posts. TB culture positivity was 1.6% (60/3642), and contamination was observed in 35.6% (1298/3642). Hospital collection was associated with lower contamination risk (adjusted OR [aOR] 0.53, 95%CI 0.40-0.69) and Mycobacteria Growth Indicator Tube vs. Löwenstein-Jensen medium with higher risk (aOR 1.88, 95%CI 1.51-2.34). CONCLUSION In routine care settings, high sample contamination and low TB culture yield were observed. This raises questions about the collection technique and storage in lower-level facilities and affirms higher risk with a liquid culture medium.

High rates of exposure to tuberculosis patients among HIV-infected health care workers in Botswana

OBJECTIVE To compare daily exposure to tuberculosis (TB) patients between HIV-infected and non-HIV-infected health care workers (HCWs), and examine the uptake of antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) among HIV-infected HCWs in Botswana. DESIGN We conducted a cross-sectional study among HCWs in 30 hospitals and clinics. We determined self-reported exposure frequency to TB patients and HIV status through in-person interviews. HCWs with unknown or negative HIV status were offered rapid HIV testing. Multivariable Poisson regression modeling with robust variance was used to estimate the association between HIV status and daily exposure to TB patients. RESULTS Of 1877 participants enrolled, 1388 (73.9%) with complete data were included in this study. Among 277 (20.0%) HIV-infected participants, 14.3% were newly diagnosed, 57.8% were on ART, and 34.3% reported previously receiving IPT. Daily exposure to TB patients was reported by respectively 48.4% and 52.9% of HIV-infected and non-infected participants. After adjusting for sex, age, occupation, and department, the rates of daily TB exposure remained similar between HIV-infected and non-HIV-infected participants (prevalence ratio 0.96, 95%CI 0.85-1.08). CONCLUSIONS We found similar rates of exposure to TB patients between HIV-infected and non-HIV-infected HCWs. Improved efforts are needed to reduce nosocomial exposure to TB among HIV-infected HCWs.