Safieh Shah

Task Shifting the Management of Non-Communicable Diseases to Nurses in Kibera, Kenya: Does It Work?

Background In sub-Saharan Africa there is an increasing need to leverage available health care workers to provide care for non-communicable diseases (NCDs). This study was conducted to evaluate adherence to Médecins Sans Frontières clinical protocols when the care of five stable NCDs (hypertension, diabetes mellitus type 2, epilepsy, asthma, and sickle cell) was shifted from clinical officers to nurses. Methods Descriptive, retrospective review of routinely collected clinic data from two integrated primary health care facilities within an urban informal settlement, Kibera, Nairobi, Kenya (May to August 2014). Results There were 3,554 consultations (2025 patients); 733 (21%) were by nurses out of which 725 met the inclusion criteria among 616 patients. Hypertension (64%, 397/616) was the most frequent NCD followed by asthma (17%, 106/616) and diabetes mellitus (15%, 95/616). Adherence to screening questions ranged from 65% to 86%, with an average of 69%. Weight and blood pressure measurements were completed in 89% and 96% of those required. Laboratory results were reviewed in 91% of indicated visits. Laboratory testing per NCD protocols was higher in those with hypertension (88%) than diabetes mellitus (67%) upon review. Only 17 (2%) consultations were referred back to clinical officers. Conclusion Nurses are able to adhere to protocols for managing stable NCD patients based on clear and standardized protocols and guidelines, thus paving the way towards task shifting of NCD care to nurses to help relieve the significant healthcare gap in developing countries.

Sodium stibogluconate and paromomycin for treating visceral leishmaniasis under routine conditions in eastern Sudan

Among patients with primary and relapse visceral leishmaniasis (VL) in eastern Sudan, we determined the proportion eligible for treatment with sodium stibogluconate and paromomycin (SSG/PM) and, of these, their demographic and clinical characteristics; initial treatment outcomes including adverse side effects requiring treatment discontinuation; treatment outcomes by 6 months; and risk factors associated with initial (slow responders) and late treatment failure (relapses and post‐kala‐azar dermal leishmaniasis, PKDL).

Unregulated usage of labour-inducing medication in a region of Pakistan with poor drug regulatory control: characteristics and risk patterns

Background In developing countries such as Pakistan, poor training of mid-level cadres of health providers, combined with unregulated availability of labour-inducing medication can carry considerable risk for mother and child during labour. Here, we describe the exposure to labour-inducing medication and its possible risks in a vulnerable population in a conflict-affected region of Pakistan. Methods A retrospective cohort study using programme data, compared the outcomes of obstetric risk groups of women treated with unregulated oxytocin, with those of women with regulated treatment. Results Of the 6379 women included in the study, 607 (9.5%) received labour-inducing medication prior to reaching the hospital; of these, 528 (87.0%) received unregulated medication. Out of 528 labour-inducing medication administrators, 197 (37.3%) traditional birth attendants (also known as dai) and 157 (29.7%) lady health workers provided unregulated treatment most frequently. Women given unregulated medication who were diagnosed with obstructed/prolonged labour were at risk for uterine rupture (RR 4.1, 95% CI: 1.7–9.9) and severe birth asphyxia (RR 3.9, 95% CI: 2.5–6.1), and those with antepartum haemorrhage were at risk for stillbirth (RR 1.8, 95% CI: 1.0–3.1). Conclusions In a conflict-affected region of Pakistan, exposure to unregulated treatment with labour-inducing medication is common, and carries great risk for mother and child. Tighter regulatory control of labour-inducing drugs is needed, and enhanced training of the mid-level cadres of healthcare workers is required.

Offering Mental Health Services in a Conflict Affected Region of Pakistan: Who Comes, and Why?

Background North West Pakistan is an area ravaged by conflict and population displacement for over three decades. Recently, drone attacks and military operations have aggravated underlying mental disorders, while access to care is limited. Among patients attending a mental health clinic integrated in district hospital conducted by psychologists; we describe service utilization, patient characteristics, presenting complaints, morbidity patterns, and follow-up details. Methodology/Principal Findings A retrospective study using routinely collected programme data was conducted from February to December 2012. A total of 1545 consultations were conducted for 928 patients (86% females). There were 71(8%) children and adolescents. An increase was observed from February to July, followed by a decline. 163 new patients (18%) were on psychotropic medication at presentation. The most common morbidity in females (36%) were symptoms of adjustment disorders and acute reactions. Depression and anxiety were common in both genders while post traumatic disorder was frequent in males (21%). Out of the 928 new patients, 639(69%) had a follow up visit planned with their psychologist, but only 220(34%) new patients returned for a follow up visit. Conclusion In a district hospital, mental health services managed by psychologists were well attended. There is a need to consider widening the current package of care to cater to the diversity of mental health disorders, gender difference, children and adolescents. Standardized diagnostic and monitoring tools would also need to be adapted accordingly and to assess patient progress. Innovative approaches to tackle the problem of the low return rate are needed.

Malaria profiles and challenges in artemisinin resistance containment in Myanmar

BackgroundThis study examined evolving malaria profiles from January, 2010 to December, 2014 to evaluate achievements and challenges of implementing measures to prevent and control spread of artemisinin resistance in Myanmar.MethodsUsing National Malaria Control Programme (NMCP) data, a cross-sectional descriptive study of 52 townships in artemisinin-resistant containment areas in Myanmar was conducted. Annual program data were analysed, and trends over time are graphically presented.ResultsIn the 52 study townships populated by 8.7 million inhabitants, malaria incidence showed a decreasing trend from 10.54 per 1 000 population in 2010 to 2.53 in 2014, and malaria mortalities also decreased from 1.83 per 100 000 population in 2010 to 0.17 in 2014. The proportion of confirmed to total tested malaria cases also decreased from 6 to 1%, while identification of cases improved. All cases from all parasites species, including Plasmodium falciparum, decreased. Coverage of LLIN (long-lasting insecticidal net)/ITN (insecticide-treated mosquito nets) and indoor residual spraying (IRS) was high in targeted areas with at-risk persons, even though the total population was not covered. In addition to passive case detection (PCD), active case detection (ACD) was conducted in hard-to-reach areas and worksites where mobile migrant populations were present. ACD improved in most areas from 2012 to 2014, but continues to need to be strengthened.ConclusionsThe findings provide useful data on the malaria situation in artemisinin-resistant initiative areas, which may be useful for the NMCP to meet its elimination goal. These profiles could contribute to better planning, implementation, and evaluation of intervention activities.

Before the bombing: High burden of traumatic injuries in Kunduz Trauma Center, Kunduz, Afghanistan

Background Médecins Sans Frontières (MSF) has been providing healthcare in Afghanistan since 1981 including specialized health services for trauma patients in Kunduz Trauma Center (KTC) from 2011. On October 3rd, 2015, a US airstrike hit the KTC, killing 42 people including 14 MSF staff. This study aims to demonstrate the impact on healthcare provision, after hospital destruction, by assessing the extent of care provided for trauma and injuries by the MSF KTC and to report on treatment outcomes from January 2014 to June 2015, three months prior to the bombing. Methods This is a descriptive, retrospective review of hospital records. All patients with traumatic injuries registered in the Emergency Department (ED) or hospitalized in In-Patients Department (IPD) and/or Intensive Care Unit (ICU) of KTC between January 2014 and June 2015 were included in the study. Results A total of 35647 patients were registered in KTC during the study period. 3199 patients registered in the ED were children aged <5 years and 310 of them were admitted including 47 to the ICU. 77.5% patients were from Kunduz province and the remaining were from other provinces. The average length of stay was 7.3 days and 3.3 days while the bed occupancy rate was an average 91.1% and 75.8% in IPD and ICU, respectively. Of 4605 IPD patients, 105 (2.3%) developed complications. Among those admitted to the ICU, 12.6% patients died. About one-third surgical interventions were carried out on an urgent basis and the major proportion (45.8%) of surgical procedures was wound surgery followed by orthopedic surgery (27.0%). Conclusions This study highlights the high burden of traumatic injuries in Kunduz province and MSF Trauma Center’s contribution to saving lives, preventing disabilities and alleviating suffering among adults and children within the region. The bombing and destruction of KTC has resulted in a specific gap in critical healthcare services for the local communities in the health system of this war-ravaged region. This suggests the urgent need for reconstruction and re-opening of the center.

International non-governmental organizations’ provision of community-based tuberculosis care for hard-to-reach populations in Myanmar, 2013–2014

BackgroundNational tuberculosis (TB) programs increasingly engage with international non-governmental organizations (INGOs), especially to provide TB care in complex settings where community involvement might be required. In Myanmar, however, there is limited data on how such INGO community-based programs are organized and how effective they are. In this study, we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar, and assess their contribution to TB case detection.MethodsWe conducted a descriptive study using program data from four INGOs and the National TB Program (NTP) in 2013–2014. For each INGO, we extracted information on its approach and key activities, the number of presumptive TB cases referred and undergoing TB testing, and the number of patients diagnosed with TB and their treatment outcomes. The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships.ResultsAll four INGOs implemented community-based TB care in challenging contexts, targeting migrants, post-conflict areas, the urban poor, and other vulnerable populations. Two recruited community volunteers via existing community health volunteers or health structures, one via existing community leaderships, and one directly involved TB infected/affected individuals. Two INGOs compensated volunteers via performance-based financing, and two provided financial and in-kind initiatives. All relied on NTP laboratories for diagnosis and TB drugs, but provided direct observation treatment support and treatment follow-up.A total of 21 995 presumptive TB cases were referred for TB diagnosis, with 7 383 (34%) new TB cases diagnosed and almost all (98%) successfully treated. The four INGOs contributed to the detection of, on average, 36% (7 383/20 663) of the total new TB cases in their respective townships (range: 15–52%).ConclusionCommunity-based TB care supported by INGOs successfully achieved TB case detection in hard-to-reach and vulnerable populations. This is vital to achieving the World Health Organization End TB Strategy targets. Strategies to ensure sustainability of the programs should be explored, including the need for longer-term commitment of INGOs.

Engagement of Public and Private Medical Facilities in Tuberculosis Care in Myanmar: Contributions and Trends Over an Eight-Year Period

AbstractsBackgroundAs part of the WHO End TB strategy, national tuberculosis (TB) programs increasingly aim to engage all private and public TB care providers. Engagement of communities, civil society organizations and public and private care provider is the second pillar of the End TB strategy. In Myanmar, this entails the public-public and public-private mix (PPM) approach. The public-public mix refers to public hospital TB services, with reporting to the national TB program (NTP). The public-private mix refers to private general practitioners providing TB services including TB diagnosis, treatment and reporting to NTP. The aim of this study was to assess whether PPM activities can be scaled-up nationally and can be sustained over time.MethodsUsing 2007–2014 aggregated program data, we collected information from NTP and non-NTP actors on 1) the number of TB cases detected and their relative contribution to the national case load; 2) the type of TB cases detected; 3) their treatment outcomes.ResultsThe total number of TB cases detected per year nationally increased from 133,547 in 2007 to 142,587 in 2014. The contribution of private practitioners increased from 11% in 2007 to 18% in 2014, and from 1.8% to 4.6% for public hospitals. The NTP contribution decreased from 87% in 2007 to 77% in 2014. A similar pattern was seen in the number of new smear (+) TB cases (31% of all TB cases) and retreatment cases, which represented 7.8% of all TB cases. For new smear (+) TB cases, adverse outcomes were more common in public hospitals, with more patients dying, lost to follow up or not having their treatment outcome evaluated. Patients treated by private practitioners were more frequently lost to follow up (8%). Adverse treatment outcomes in retreatment cases were particularly common (59%) in public hospitals for various reasons, predominantly due to patients dying (26%) or not being evaluated (10%). In private clinics, treatment failure tended to be more common (8%).ConclusionsThe contribution of non-NTP actors to TB detection at the national level increased over time, with the largest contribution by private practitioners involved in PPM. Treatment outcomes were fair. Our findings confirm the role of PPM in national TB programs. To achieve the End TB targets, further expansion of PPM to engage all public and private medical facilities should be targeted.

Procurement and Supply Management System for MDR-TB in Nigeria: Are the Early Warning Targets for Drug Stock Outs and Over Stock of Drugs Being Achieved?

Background The World Health Organisation (WHO) introduced the twelve early warning indicators for monitoring and evaluating drug Procurement and Supply management (PSM) systems, intended to prevent drug stock-outs and overstocking. Nigeria- one of the high Multi Drug Resistant Tuberculosis (MDR-TB) burden countries, scaled-up treatment in 2012 with the concurrent implementation of a PSM system. Method We evaluated how well this system functioned using the WHO indicators, including all seven MDR-TB treatment centres in the country that were functional throughout 2013. Results The quantity of MDR-TB drugs ordered for 2013 matched the annual forecast and all central orders placed during the year were delivered in full and on time. Drug consumption was 81%–106% of the quantity allocated for routine consumption. Timely submission of complete inventory reports ranged from 86–100%, late submissions being 5–15 days late. Forty to 71% of treatment centres placed a drug order when stock was below the minimum level of three months. The proportion of drug orders received at the treatment centres in full and on time ranged from 29–80%, late orders being 1–19 days late. Conclusion The PSM was found to be performing well in terms of forecasting and procurement of MDR-TB drugs, but there were shortcomings in drug distribution, reporting at treatment centre level and in drug order placements. Despite these gaps, there were no stock outs. These findings indicate that where it matters most, namely ensuring that no drug stock outs affect patient management, the PSM system is effective. Addressing the observed shortcomings will help to strengthen the existing PSM system in anticipation of a growing MDR-TB case burden in the country.

Blended SORT-IT for operational research capacity building: the model, its successes and challenges

ABSTRACT The Structured Operational Research Training Initiative (SORT-IT) has been shown to be very effective in strengthening capacity for conducting operational research, publishing in scientific journals and fostering policy and practice change. The ‘classic’ model includes three face-to-face modules during which, respectively, a study protocol, a data analysis plan, and a manuscript are elaborated. Meanwhile, the lectures of the SORT-IT are available online as YouTube videos. Given the availability of this online material and the experiences with online mentorship of the faculty, we piloted a first blended distance/residential SORT-IT. To inform future implementers of our experience with blended operational research courses, we summarize the model, successes, and challenges of this approach in this perspective paper. The blended SORT-IT consisted of an online phase, covering modules 1 and 2, followed by a face-to-face writing module 3. Four out of six participants successfully completed the course, and submitted a manuscript to a peer-reviewed journal within four weeks of completing module 3. A blended approach may make the SORT-IT course more accessible to future participants and may favour the adoption of the course by other institutions, such as national Ministries of Health.