Sonak D. Pastakia

Screening for diabetes and hypertension in a rural low income setting in western Kenya utilizing home-based and community-based strategies.

BackgroundThe burdens of hypertension and diabetes are increasing in low- and middle-income countries (LMICs). It is important to identify patients with these conditions early in the disease process. The goal of this study, therefore, is to compare community- versus home-based screening for hypertension and diabetes in Kenya.MethodsThis was a feasibility study conducted by the Academic Model Providing Access to Healthcare (AMPATH) program in Webuye, a town in western Kenya. Home-based (door-to-door) screening occurred in March 2010 and community-based screening in November 2011. HIV counselors were trained to screen for diabetes and hypertension in the home-based screening with local district hospital based staff conducting the community-based screening. Participants >18 years old qualified for screening in both groups. Counselors referred all participants with a systolic blood pressure (SBP) ≥160 mmHg and/or a random blood glucose ≥7 mmol/L (126 mg/dL) to a local clinic for follow-up. Differences in likelihood of screening positive between the two strategies were compared using Fischer’s Exact Test. Logistic regression models were used to identify factors associated with the likelihood of following-up after a positive screening.ResultsThere were 236 participants in home-based screening: 13 (6%) had a SBP ≥160 mmHg, and 54 (23%) had a random glucose ≥ 7 mmol/L. There were 346 participants in community-based screening: 35 (10%) had a SBP ≥160 mmHg, and 27 (8%) had a random glucose ≥ 7 mmol/L. Participants in community-based screening were twice as likely to screen positive for hypertension compared to home-based screening (OR=1.93, P=0.06). In contrast, participants were 3.5 times more likely to screen positive for a random blood glucose ≥7 mmol/L with home-based screening (OR=3.51, P<0.01). Rates for following-up at the clinic after a positive screen were low for both groups with 31% of patients with an elevated SBP returning for confirmation in both the community-based and home-based group (P=1.0). Follow-up after a random glucose was also low with 23% returning in the home-based group and 22% in the community-based group (P=1.0).ConclusionCommunity- or home-based screening for diabetes and hypertension in LMICs is feasible. Due to low rates of follow-up, screening efforts in rural settings should focus on linking cases to care.

Diabetes in sub-Saharan Africa: from clinical care to health policy

Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA (Prof R Atun FRCP, Prof T Bärnighausen MD, I Postolovska ScD, S Vollmer PhD, B Ammon, A Annamreddi, A Awasthi, S Bhadriraju, J Chai MPH, J Ho BS, S S Kakarmath MBBS MS, R Kharel, M A Kyle, S C Lee MD, A Lichtman MD, J Manne-Goehler MD, M Nair MPH, O L O Okafor MPH, O Okunade MD, D Sando, A Sharma MPH, A S Syed MPH); Harvard Medical School, Harvard University, Boston, MA, USA (Prof R Atun, A Binagwaho MD, P Chipendo MD, J Manne-Goehler); Centre for Global Health, King’s College London, Weston Education Centre, London, UK (J I Davies MD); MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Education Campus, University of Witwatersrand, Parktown, South Africa (J I Davies); University of Bristol, Bristol, UK (E A M Gale FRCP); Muhimbili University of Health and Allied Sciences, and Abbas Medical Centre, Dar es Salaam, Tanzania (Z G Abbas MMed); Institute of Public Health, Faculty of Diabetes in sub-Saharan Africa: from clinical care to health policy

Collaborative partnership for clinical pharmacy services in Kenya.

PURPOSE A collaborative partnership for clinical pharmacy services in Kenya is described. SUMMARY Purdue University School of Pharmacy and Pharmaceutical Sciences (PUSOPPS) agreed to collaborate with the United States Agency for International Development-Academic Model for Providing Access to Healthcare (USAID-AMPATH) partnership to provide pharmacy services necessary for patients infected with human immunodeficiency virus (HIV) in Kenya. In addition to assisting Kenyan collaborators, the full-time, onsite faculty member from PUSOPPS serves as a preceptor to pharmacy clerkship students from PUSOPPS and the University of Nairobi in the delivery of clinical pharmacy services in inpatient and outpatient settings. Through PUSOPPSs unique collaboration, Kenyan pharmacy technologist students and University of Nairobi pharmacy students partner with clerkship students from PUSOPPS to participate in eight-week rotations. In addition to inpatient activities, students spend one day each week at one of the rural HIV clinics or observing one of the burgeoning specialized care clinics. Students also participate in public health activities, such as providing adherence counseling for HIV-infected patients, participating in door-to-door HIV counseling and testing, and preparing educational and recreational activities for pediatric patients. PUSOPPSs sustainable involvement with this program has addressed many of the immediate pharmacy needs of providing antiretroviral therapy and medications for opportunistic infections throughout western Kenya. CONCLUSION The collaboration between PUSOPPS and USAID-AMPATH in Eldoret, Kenya, has provided a bilateral educational exchange for Kenyan and American pharmacy students and has allowed for year-round clinical pharmacy services in both inpatient and outpatient settings.

Engaging the Entire Care Cascade in Western Kenya: A Model to Achieve the Cardiovascular Disease Secondary Prevention Roadmap Goals

Cardiovascular disease (CVD) is the leading cause of death in the world, with a substantial health and economic burden confronted by low- and middle-income countries. In low-income countries such as Kenya, there exists a double burden of communicable and noncommunicable diseases, and the CVD profile includes many nonatherosclerotic entities. Socio-politico-economic realities present challenges to CVD prevention in Kenya, including poverty, low national spending on health, significant out-of-pocket health expenditures, and limited outpatient health insurance. In addition, the health infrastructure is characterized by insufficient human resources for health, medication stock-outs, and lack of facilities and equipment. Within this socio-politico-economic reality, contextually appropriate programs for CVD prevention need to be developed. We describe our experience from western Kenya, where we have engaged the entire care cascade across all levels of the health system, in order to improve access to high-quality, comprehensive, coordinated, and sustainable care for CVD and CVD risk factors. We report on several initiatives: 1) population-wide screening for hypertension and diabetes; 2) engagement of community resources and governance structures; 3) geographic decentralization of care services; 4) task redistribution to more efficiently use of available human resources for health; 5) ensuring a consistent supply of essential medicines; 6) improving physical infrastructure of rural health facilities; 7) developing an integrated health record; and 8) mobile health (mHealth) initiatives to provide clinical decision support and record-keeping functions. Although several challenges remain, there currently exists a critical window of opportunity to establish systems of care and prevention that can alter the trajectory of CVD in low-resource settings.

The oncology pharmacy in cancer care delivery in a resource-constrained setting in western Kenya

The movement to deliver cancer care in resource-limited settings is gaining momentum, with particular emphasis on the creation of cost-effective, rational algorithms utilizing affordable chemotherapeutics to treat curable disease. The delivery of cancer care in resource-replete settings is a concerted effort by a team of multidisciplinary care providers. The oncology pharmacy, which is now considered integral to cancer care in resourced medical practice, developed over the last several decades in an effort to limit healthcare provider exposure to workplace hazards and to limit risk to patients. In developing cancer care services in resource-constrained settings, creation of oncology pharmacies can help to both mitigate the risks to practitioners and patients, and also limit the costs of cancer care and the environmental impact of chemotherapeutics. This article describes the experience and lessons learned in establishing a chemotherapy pharmacy in western Kenya.

Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya

Summary.  Background: It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub‐Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease. Objective: To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource‐rich settings. Methods: A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. Wilcoxon’s rank sum analyses were used to establish predictors of TTR. Results: For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow‐up of > 120 days were positively associated with a higher TTR (P < 0.05) whereas venous thromboembolism, history of tuberculosis, HIV and a duration of follow‐up of < 120 days were associated with having a lower TTR (P < 0.05). Conclusions: The performance of the MTRH anticoagulation clinic is non‐inferior to published metrics on the performance of clinics in resource‐rich settings.

Retrospective Analysis of the Efficacy of Gemcitabine for Previously Treated AIDS-Associated Kaposi's Sarcoma in Western Kenya

Objectives: Evaluation of outcomes in the use of single-agent gemcitabine for the treatment of AIDS-associated Kaposi’s sarcoma (KS) in a western Kenyan cancer treatment program. Methods: Retrospective chart review of all patients with KS treated with single agent gemcitabine following failure of first-line Adriamycin, bleomycin, and vincristine (ABV). Baseline demographics were collected, and clinicians’ assessments of response were utilized to fill out objective criteria for both response as well as symptom benefit assessment. Results: Twenty-three patients with KS who had previously failed first-line therapy with ABV were evaluated. Following treatment, 22 of the 23 patients responded positively to treatment with stable disease or better. Of the 18 patients who had completed therapy, with a median follow-up of 5 months, 12 patients had no documented progression. Conclusions: Treatment options in the resource-constrained setting are limited, both by financial constraints as well as the need to avoid myelotoxicity, which is associated with high morbidity in this treatment setting. This work shows that gemcitabine has promising activity in KS, with both objective responses and clinical benefit observed in this care setting. Gemcitabine as a single agent merits further investigation for AIDS-associated KS.

Building Sustainable Capacity for Cardiovascular Care at a Public Hospital in Western Kenya.

Cardiovascular disease deaths are increasing in low- and middle-income countries and are exacerbated by health care systems that are ill-equipped to manage chronic diseases. Global health partnerships, which have stemmed the tide of infectious diseases in low- and middle-income countries, can be similarly applied to address cardiovascular diseases. In this review, we present the experiences of an academic partnership between North American and Kenyan medical centers to improve cardiovascular health in a national public referral hospital. We highlight our stepwise approach to developing sustainable cardiovascular services using the health system strengthening World Health Organization Framework for Action. The building blocks of this framework (leadership and governance, health workforce, health service delivery, health financing, access to essential medicines, and health information system) guided our comprehensive and sustainable approach to delivering subspecialty care in a resource-limited setting. Our experiences may guide the development of similar collaborations in other settings.

An elective pharmaceutical care course to prepare students for an advanced pharmacy practice experience in Kenya.

Objective. To develop a prerequisite elective course to prepare students for an advanced pharmacy practice experience (APPE) in Kenya. Design. The course addressed Kenyan culture, travel preparation, patient care, and disease-state management. Instructional formats used were small-group discussions and lectures, including some Web-based presentations by Kenyan pharmacists on disease states commonly treated in Kenya. Cultural activities include instruction in conversational and medical Kiswahili and reading of a novel related to global health programs. Assessment. Student performance was assessed using written care plans, quizzes, reflection papers, a formulary management exercise, and pre- and post-course assessments. Student feedback on course evaluations indicated that the course was well received and students felt prepared for the APPE. Conclusion. This course offered a unique opportunity for students to learn about pharmacy practice in global health and to apply previously acquired skills in a resource-constrained international setting. It prepares students to actively participate in clinical care activities during an international APPE.

Pilot study of single-use obstetric emergency medical kits to reduce maternal mortality

To describe the experience at a single facility regarding single‐use emergency medication kits to treat obstetric emergencies in a resource‐poor setting.