Ousman Nyan

Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in The Gambia: the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) study

BACKGROUND Despite the introduction of immunisation for hepatitis B virus (HBV) in the 1990s, HBV-related morbidity and mortality remain high in sub-Saharan Africa. Identification and treatment of asymptomatic people with chronic HBV infection should reduce the disease burden. We therefore assessed the feasibility of a screen-and-treat programme for HBV infection in The Gambia, west Africa, and estimated the proportion of HBV-infected people who had significant liver disease in need of treatment. METHODS Between Dec 7, 2011, and Jan 24, 2014, individuals living in randomly selected communities in western Gambia were offered hepatitis B surface antigen (HBsAg) screening via a point-of-care test. The test was also offered to potential blood donors attending the central hospital in the capital, Banjul. HBsAg-positive individuals were invited for a comprehensive liver assessment and were offered treatment according to international guidelines. We defined linkage to care as visiting the liver clinic at least once. Eligibility for treatment was judged in accordance with the 2012 European Association for the Study of the Liver guidelines. FINDINGS HBsAg screening was accepted by 5980 (weighted estimate 68·9%, 95% CI 65·0-72·4) of 8170 adults from 27 rural and 27 urban communities and 5559 (81·4%, 80·4-82·3) of 6832 blood donors. HBsAg was detected in 495 (8·8%, 7·9-9·7) individuals in communities and 721 (13·0%, 12·1-13·9) blood donors. Prevalence was higher in men (239 [10·5%, 8·9-12·1] of 2328 men vs 256 [7·6%, 6·5-8·7] of 3652 women; p=0·004) and middle-aged participants. Linkage to care was high in the communities, with 402 (81·3%) of 495 HBsAg-positive individuals attending the clinic. However, only 300 (41·6%) of 721 HBsAg-positive people screened at the blood bank linked into care. Of those who attended the clinic, 18 (4·4%, 2·5-7·7) patients from the communities and 29 (9·7%, 6·8-13·6) from the blood bank were eligible for treatment. Male sex was strongly associated with treatment eligibility (odds ratio 4·35, 1·50-12·58; p=0·007). INTERPRETATION HBV infection remains highly prevalent in The Gambia. The high coverage of community-based screening, good linkage into care, and the small proportion of HBsAg carriers who need treatment suggest that large-scale screening and treatment programmes are feasible in sub-Saharan Africa. FUNDING European Commission (FP7).

Medical students’ choices of specialty in The Gambia: the need for career counseling

BackgroundUnderstanding preferences for specialties by medical students and the factors driving choices assists policy makers in ensuring optimal spread of personnel across disciplines.MethodsThis cross-sectional survey using self-administered structured questionnaires was conducted on consenting students of the first medical school in The Gambia, established in 1999. Data collection was in June/July 2011. Questions were on sociodemographic characteristics of students, their parents, factors related to career preferences and opinions about counseling services. Data were analysed using JMP 8.0 software.ResultsRespondents were 52.4% of 202 eligible students. Mean age was 24.1 ± 5.0 years. Females constituted 54.7%. Muslims were 72.7% while Gambians formed 77.0%. Commonest specialties chosen by females were Obstetrics/Gynaecology, Paediatrics and Surgery in that order, while males preferred Internal Medicine, Surgery and Obstetrics/Gynaecology. Commonest factors influencing choices by females were ‘focus on urgent care’ (65.5%) and ‘intellectual content of specialty’ (56.9%). For males, these were ‘intellectual content of specialty’ (60.4%) and ‘focus on urgent care’ / ‘individual’s competence’ (50.0% each). More females (30.0%) than males (23.0%) had ever received career counseling, but all students desired it.ConclusionsSignificant gender differences exist in specialty choices and factors influencing these choices amongst these students. All want career counseling.

Women's experiences of pregnancy, childbirth, and the postnatal period in the Gambia: A qualitative study

OBJECTIVE In sub-Saharan African countries, there are unique cultural factors and adverse physical conditions that contribute to womens experiences of pregnancy and birth. The objective of this study was to qualitatively explore womens experiences of pregnancy, childbirth, the postnatal period, and maternal psychological distress in The Gambia. DESIGN AND METHODS Semi-structured interviews were carried out with 55 women who had given birth within the previous year. RESULTS Thematic analysis identified five themes: (1) transition to adulthood, (2) physical difficulties, (3) value of children in relation to others, (4) children as a strain, and (5) going through it alone. The results suggest that having a child is a defining point in womens lives associated with happiness and joy. However, women also described situations which could lead to unhappiness and distress in the perinatal period. A child conceived out of wedlock or a baby girl can be sources of distress because of negative cultural perceptions. The strain of having a child, particularly the additional financial burden, and minimal support from men were also a concern for women. Finally, women recognized the danger associated with delivery and expressed recurrent worries of complications during childbirth which could result in the death of them or the baby. CONCLUSIONS Further research is needed to identify women vulnerable to psychological distress so that health services and target interventions can be developed accordingly.

20-Years of Population-Based Cancer Registration in Hepatitis B and Liver Cancer Prevention in The Gambia, West Africa

Background The Gambia Hepatitis Intervention Study (GHIS) was designed as a randomised control trial of infant hepatitis B vaccination applied to public health policy, with the main goal of preventing primary liver cancer later in adult life in The Gambia. To that effect, the National Cancer Registry of The Gambia (NCR), a population-based cancer registry (PBCR), was established in 1986 to actively collect data on all cancer diagnosis nation-wide. We extracted 20-years (1990-2009) of data to assess for the first time, the evolution of the most common cancers, also describe and demonstrate the role of the PBCR in a hepatitis B and liver cancer prevention programme in this population. Methods and Findings We estimated Age-Standardised Incidence Rates (ASR (W)) of the most common cancers registered during the period by gender. The registration period was divided into four 5-year intervals and incidence rates were estimated for each interval. The most common cancers in males were liver, prostate, lung plus bronchus, non-Hodgkin lymphoma (NHL) and stomach, accounting for 60%, 5%, 4%, 5% and 3%, respectively. Similarly, cancers of the cervix uteri, liver, breast and NHL, were the most common in females, accounting for 33%, 24%, 11% and 4% of the female cancers, respectively. Conclusions Cancer incidence has remained relatively stable over time, but as shown elsewhere in sub-Saharan Africa the disease is a threat in The Gambia. The infection related cancers which are mostly preventable (HBV in men and HPV/HIV in women) were the most common. At the moment the data is not enough to detect an effect of hepatitis B vaccination on liver cancer incidence in The Gambia. However, we observed that monitoring case occurrence through PBCR is a key public health pre-requisite for rational planning and implementation of targeted interventions for improving the health of the population.

Birth order and risk of hepatocellular carcinoma in chronic carriers of hepatitis B virus: a case-control study in The Gambia.

Early age at infection with Hepatitis B virus (HBV) increases the risk of chronic infection. Moreover, early HBV infection may further independently increase the risk of hepatocellular carcinoma (HCC) beyond its effect on chronicity.

The prevalence and burden of symptoms in patients with chronic liver diseases in The Gambia, West Africa

In The Gambia, the smallest country in the African continent with a population of 1.73 million, hepatocellular carcinoma (HCC) is the most frequent type of cancer. Curative treatment is often unavailable because of late presentation to hospital and limited health infrastructure. Palliative care has been provided by a single non-governmental organisation (NGO) since 2004, but its coverage is limited. To date, there is no published data on the symptom burden of cancer patients in The Gambia. This cross-sectional study aimed to determine the symptom prevalence and burden among patients with HCC in The Gambia. In addition, the prevalence and burden of symptoms in patients with other non-malignant chronic liver diseases were estimated and compared with those of HCC patients.

Standard operating procedures improve acute neurologic care in a sub-Saharan African setting

Objective: Quality of neurologic emergency management in an under-resourced country may be improved by standard operating procedures (SOPs). Methods: Neurologic SOPs were implemented in a large urban (Banjul) and a small rural (Brikama) hospital in the Gambia. As quality indicators of neurologic emergency management, performance of key procedures was assessed at baseline and in the first and second implementation years. Results: At Banjul, 100 patients of the first-year intervention group exhibited higher rates of general procedures of emergency management than 105 control patients, such as neurologic examination (99.0% vs 91.4%; p < 0.05) and assessments of respiratory rate (98.0% vs 81.9%, p < 0.001), temperature (60.0% vs 36.2%; p < 0.001), and glucose levels (73.0% vs 58.1%; p < 0.05), in addition to written directives by physicians (96.0% vs 88.6%, p < 0.05), whereas assessments of other vital signs remained unchanged. In stroke patients, rates of stroke-related procedures increased: early CT scanning (24.3% vs 9.9%; p < 0.05), blood count (73.0% vs 49.3%; p < 0.01), renal and liver function tests (50.0% vs 5.6%, p < 0.001), aspirin prophylaxis (47.3% vs 9.9%; p < 0.001), and physiotherapy (41.9% vs 4.2%; p < 0.001). Most effects persisted until the second-year evaluation. SOP implementation was similarly feasible and beneficial at the Brikama hospital. However, outcomes did not significantly differ in the hospitals. Conclusions: Implementing SOPs is a realistic, low-cost option for improving process quality of neurologic emergency management in under-resourced settings. Classification of evidence: This study provides Class IV evidence that, for patients with suspected neurologic emergencies in sub-Saharan Africa, neurologic SOPs increase the rate of performance of guideline-recommended procedures.

Spinocerebellar ataxia type 2 in The Gambia: A case report

A 40-year-old black male from Busumbala village, in suburban Gambia, presented to the Medicine Out Patient Department of our Teaching Hospital in the company of two of his brothers, with a history of gait and speech problems, and resting tremor of the head and hands. These abnormalities were of gradual onset with a slowly progressive course. Clinical manifestations of neurologic disease began about ten years ago. There were no histories of head trauma, encephalitis or drug intake. A brain scan showed no abnormalities apart from cerebellar atrophy. The index case was subjected to further clinical and genetic characterization. The study protocol was approved by the Research and Publication Committee at the School of Medicine, and the informed consent was obtained from the patient. The family history showed that the index case (II-6) had an older brother (II-3) who suffered from similar condition to that of the index case (Fig. 1). This brother had five children as a result of two different marriages; so far, one of his three daughters is also affected (III-4). In addition, the index case has a half-brother who is also affected (II-9). As the common ancestor to all of them is the index case father (I-2), it is therefore assumed that the father is the founder of this condition in the family, even though he died older than 70 years of age with no neurological problem. Genetic anticipation was apparent in the family, where individual III-4 became sick 23 years earlier than her father (II3) did, and about 15 years earlier than her uncles (II-6 and II-9).

First case with Huntington's disease in The Gambia

A 52-year old black male from the Greater Banjul Area presented to the Medicine Out Patient Department in the company of his son, with a history of abnormal movements of limbs and face. These abnormal movements were of gradual onset with progressive course. Clinical manifestations of neurologic disease began about six years ago. Initial symptoms included weakness in the lower limbs, cramps and involuntary movement of head, trunk and limbs. There was no history of drug intake such as neuroleptics, levodopa, phenytoin or cocaine. Moreover, there was no history of systemic conditions such as systemic lupus erythematosus (SLE), hyperglycemia, AIDS, thyrotoxicosis, polycythemia vera or paraneoplastic syndrome, neither pointers towards Sydenhams chorea or Wilsons disease. By interviewing the affected patient and close relatives it was possible to establish family records for the patients condition (Fig. 1A). Actually, the index case (III-7) had an older sister (III-1) who died with a similar condition to that of the index case. However, no further clues

Author response: Standard operating procedures improve acute neurologic care in a sub-Saharan African setting

We thank Dr. Chin for the comments on our article.1 We agree that the study was performed under experimental conditions. This limitation, aimed to be minimized by assessment conditions that were similar before and after standard operating procedure (SOP) implementation and by the absence of provision of additional resources, was discussed.1 The statement that sub-Saharan African countries face crucial challenges that are, in the end, associated with the severe financial constrains is true. This was documented in our study,1 including the problem of CT performance due to unsettled payment questions. SOPs are only one of several steps, among which are long-term international financial support and cooperation, structural measures (such as health insurance systems), and systematic training of neurologists (thereby avoiding brain drain). Yet, what can be done today? As long as the financial support and the structural frameworks remain suboptimal, SOPs to make better use of the still available, although limited, personnel and technical resources (e.g., adjustment of physiologic measures, aspirin prophylaxis, or physiotherapy) are a relevant step towards guideline-recommended stroke management. As suggested by Dr. Chin, these might be complemented by further SOPs that focus on postemergency management and measures for prevention.2