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Philippin H, Matayan EN, Knoll KM, Macha E, Mbishi S, Makupa A, Matsinhe CD, da Gama IV, Monjane MJ, Ncheda JA, Mulobuana FAF, Muna E, Guylene NF, Gazzard G, Marques AP, Shah P, Macleod D, Makupa W, Burton MJ. Differentiating stages of functional vision loss from glaucoma using the Disc Damage Likelihood Scale and cup:disc ratio. Br J Ophthalmol 2024; 108:349-356. [PMID: 36653163 PMCID: PMC10894823 DOI: 10.1136/bjo-2022-321643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 01/07/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Glaucoma staging is critical for treatment planning but has rarely been tested in severe/end-stage disease. We compared the performance of the Disc Damage Likelihood Scale (DDLS) and cup:disc ratio (CDR) using a functional glaucoma staging system (GSS) as the reference standard. METHODS Post hoc analysis of a randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Tanzania. Eligible participants (aged ≥18 years) with open-angle glaucoma, intraocular pressure (IOP) of >21 mm Hg, were randomised to timolol 0.5% eye drops or selective laser trabeculoplasty. Fundoscopy established vertical and horizontal CDRs and DDLS. Visual acuity and static visual fields were graded (GSS). The study used area under the receiver operating characteristic (AROC) curves and Spearman's rank correlation coefficients to compare staging systems. Logistic regression with generalised estimating equations determined risk factors of functional severe/end-stage glaucoma. RESULTS 382 eyes (201 participants) were evaluated; 195 (51%) had severe or end-stage glaucoma; mean IOP was 26.7 (SD 6.9) mm Hg. DDLS yielded an AROC of 0.90 (95% CI 0.87 to 0.93), vertical cup:disc ratio (vCDR) of 0.88 (95% CI 0.85 to 0.91, p=0.048) for identifying severe/end-stage disease. Correlation coefficients comparing GSS to DDLS and vCDRs were 0.73 and 0.71, respectively. Advanced structural stages, vision impairment, higher IOP and less financial resources were risk factors of functional severe/end-stage glaucoma. CONCLUSION This study indicates that both structural staging systems can differentiate severe/end-stage glaucoma from less severe disease, with a moderate advantage of DDLS over CDR. Clinical examination of the optic disc plays an important role in addition to functional assessment when managing severe/end-stage glaucoma.
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Affiliation(s)
- Heiko Philippin
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine Department of Clinical Research, London, UK
- Eye Centre, Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Einoti Naino Matayan
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
- Kilimanjaro Christian Medical University College, Moshi, Tanzania, United Republic of
| | - Karin Marianne Knoll
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - Edith Macha
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - Sia Mbishi
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - Andrew Makupa
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
- Kilimanjaro Christian Medical University College, Moshi, Tanzania, United Republic of
| | - Cristóvão Daniel Matsinhe
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
- Provincial Hospital of Pemba, Pemba, Mozambique
| | - Isac Vasco da Gama
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
- Hospital Central de Quelimane, Quelimane, Mozambique
| | - Mário Jorge Monjane
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - Joyce Awum Ncheda
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
- Presbyterian Eye Hospital, Bafoussam, Cameroon
| | | | - Elisante Muna
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - Nelly Fopoussi Guylene
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
- Eye Department, Cameroon Baptist Convention Health Services, Douala, Cameroon
| | - Gus Gazzard
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - Ana Patricia Marques
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine Department of Clinical Research, London, UK
| | - Peter Shah
- Institute of Ophthalmology, University College London, London, UK
- Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Macleod
- MRC International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - William Makupa
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
- Kilimanjaro Christian Medical University College, Moshi, Tanzania, United Republic of
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine Department of Clinical Research, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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Cleland CR, Bascaran C, Makupa W, Shilio B, Sandi FA, Philippin H, Marques AP, Egan C, Tufail A, Keane PA, Denniston AK, Macleod D, Burton MJ. Artificial intelligence-supported diabetic retinopathy screening in Tanzania: rationale and design of a randomised controlled trial. BMJ Open 2024; 14:e075055. [PMID: 38272554 PMCID: PMC10824006 DOI: 10.1136/bmjopen-2023-075055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 01/12/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Globally, diabetic retinopathy (DR) is a major cause of blindness. Sub-Saharan Africa is projected to see the largest proportionate increase in the number of people living with diabetes over the next two decades. Screening for DR is recommended to prevent sight loss; however, in many low and middle-income countries, because of a lack of specialist eye care staff, current screening services for DR are not optimal. The use of artificial intelligence (AI) for DR screening, which automates the grading of retinal photographs and provides a point-of-screening result, offers an innovative potential solution to improve DR screening in Tanzania. METHODS AND ANALYSIS We will test the hypothesis that AI-supported DR screening increases the proportion of persons with true referable DR who attend the central ophthalmology clinic following referral after screening in a single-masked, parallel group, individually randomised controlled trial. Participants (2364) will be randomised (1:1 ratio) to either AI-supported or the standard of care DR screening pathway. Participants allocated to the AI-supported screening pathway will receive their result followed by point-of-screening counselling immediately after retinal image capture. Participants in the standard of care arm will receive their result and counselling by phone once the retinal images have been graded in the usual way (typically after 2-4 weeks). The primary outcome is the proportion of persons with true referable DR attending the central ophthalmology clinic within 8 weeks of screening. Secondary outcomes, by trial arm, include the proportion of persons attending the central ophthalmology clinic out of all those referred, sensitivity and specificity, number of false positive referrals, acceptability and fidelity of AI-supported screening. ETHICS AND DISSEMINATION The London School of Hygiene & Tropical Medicine, Kilimanjaro Christian Medical Centre and Tanzanian National Institute of Medical Research ethics committees have approved the trial. The results will be submitted to peer-reviewed journals for publication. TRIAL REGISTRATION NUMBER ISRCTN18317152.
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Affiliation(s)
- Charles R Cleland
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Covadonga Bascaran
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - William Makupa
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Bernadetha Shilio
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Frank A Sandi
- Department of Ophthalmology, University of Dodoma School of Medicine and Nursing, Dodoma, Tanzania
| | - Heiko Philippin
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- Eye Centre, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Ana Patricia Marques
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Catherine Egan
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
| | - Adnan Tufail
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
| | - Pearse A Keane
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
| | - Alastair K Denniston
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
- National Institute for Health and Care Research, Birmingham Biomedical Research Centre, Birmingham, UK
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
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Artese AL, Winthrop HM, Bohannon L, Lew MV, Johnson E, MacDonald G, Ren Y, Pastva AM, Hall KS, Wischmeyer PE, Macleod D, Molinger J, Barth S, Jung SH, Cohen HJ, Bartlett DB, Sung AD. A pilot study to assess the feasibility of a remotely monitored high-intensity interval training program prior to allogeneic hematopoietic stem cell transplantation. PLoS One 2023; 18:e0293171. [PMID: 38032994 PMCID: PMC10688680 DOI: 10.1371/journal.pone.0293171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 10/05/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION Although allogeneic hematopoietic stem cell transplantation (HCT) can be a curative therapy for hematologic disorders, it is associated with treatment-related complications and losses in cardiorespiratory fitness and physical function. High-intensity interval training (HIIT) may be a practical way to rapidly improve cardiorespiratory fitness and physical function in the weeks prior to HCT. The primary aim of this study was to assess the feasibility of implementing a pre-HCT home-based HIIT intervention. The secondary aim was to evaluate pre to post changes in cardiorespiratory fitness and physical function following the intervention. METHODS This was a single-arm pilot study with patients who were scheduled to undergo allogeneic HCT within six months. Patients were instructed to complete three 30-minute home-based HIIT sessions/week between the time of study enrollment and sign-off for HCT. Sessions consisted of a 5-minute warm-up, 10 high and low intervals performed for one minute each, and a 5-minute cool-down. Prescribed target heart rates (HR) for the high- and low-intensity intervals were 80-90% and 50-60% of HR reserve, respectively. Heart rates during HIIT were captured via an Apple Watch and were remotely monitored. Feasibility was assessed via retention, session adherence, and adherence to prescribed interval number and intensities. Paired t-tests were used to compare changes in fitness (VO2peak) and physical function [Short Physical Performance Battery (SPPB), 30-second sit to stand, and six-minute walk test (6MWT)] between baseline and sign-off. Pearson correlations were used to determine the relationship between intervention length and changes in cardiorespiratory fitness or functional measures. RESULTS Thirteen patients (58.8±11.6 years) participated in the study, and nine (69.2%) recorded their training sessions throughout the study. Median session adherence for those nine participants was 100% (IQR: 87-107). Adherence to intervals was 92% and participants met or exceeded prescribed high-intensity HR on 68.8±34.8% of intervals. VO2peak improved from baseline to sign-off (14.6±3.1 mL/kg/min to 17.9±3.3 mL/kg/min; p<0.001). 30-second sit to stand and SPPB chair stand scores significantly improved in adherent participants. Improvements in 30-second sit to stand (13.8±1.5 to 18.3±3.3 seconds) and 6MWT (514.4±43.2 to 564.6±19.3) exceeded minimal clinically important improvements established in other chronic disease populations, representing the minimum improvement considered meaningful to patients. CONCLUSIONS Findings demonstrate that implementing a pre-HCT home-based remotely monitored HIIT program is feasible and may provide benefits to cardiorespiratory fitness and physical function.
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Affiliation(s)
- Ashley L. Artese
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America
- Department of Exercise Science and Health Promotion, Florida Atlantic University, Boca Raton, Florida, United States of America
| | - Hilary M. Winthrop
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Lauren Bohannon
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Meagan V. Lew
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Ernaya Johnson
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Grace MacDonald
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, North Carolina, United States of America
- Division of Medical Oncology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Yi Ren
- Duke Cancer Institute Biostatistics Shared Resources, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Amy M. Pastva
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America
- Department of Orthopaedic Surgery, Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Katherine S. Hall
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America
- Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, United States of America
- Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina, United States of America
| | - Paul E. Wischmeyer
- Duke University Hospital, Department of Anesthesiology and Surgery, Durham North Carolina, United States of America
| | - David Macleod
- Human Pharmacology and Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Jeroen Molinger
- Duke University Hospital, Department of Anesthesiology and Surgery, Durham North Carolina, United States of America
- Human Pharmacology and Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Stratton Barth
- Duke University Hospital, Department of Anesthesiology and Surgery, Durham North Carolina, United States of America
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - David B. Bartlett
- Division of Medical Oncology, Duke University School of Medicine, Durham, North Carolina, United States of America
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Anthony D. Sung
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
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Allen LN, Nkomazana O, Kumar Mishra S, Ratshaa B, Ho-Foster A, Rono H, Roshan A, Macleod D, Kim M, Patricia Marques A, Bolster N, Burton M, Gichangi M, Karanja S, Bastawrous A. Sociodemographic characteristics of community eye screening participants: protocol for cross-sectional equity analyses in Botswana, India, Kenya, and Nepal. Wellcome Open Res 2023; 7:144. [PMID: 37485295 PMCID: PMC10357071 DOI: 10.12688/wellcomeopenres.17768.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 07/25/2023] Open
Abstract
Background Attendance rates for eye clinics are low across low- and middle-income countries (LMICs) and exhibit marked sociodemographic inequalities. We aimed to quantify the association between a range of sociodemographic domains and attendance rates from vision screening in programmes launching in Botswana, India, Kenya and Nepal. Methods We performed a literature review of international guidance on sociodemographic data collection. Once we had identified 13 core candidate domains (age, gender, place of residence, language, ethnicity/tribe/caste, religion, marital status, parent/guardian status, place of birth, education, occupation, income, wealth) we held workshops with researchers, academics, programme implementers, and programme designers in each country to tailor the domains and response options to the national context, basing our survey development on the USAID Demographic and Health Survey model questionnaire and the RAAB7 eye health survey methodology. The draft surveys were reviewed by health economists and piloted with laypeople before being finalised, translated, and back-translated for use in Botswana, Kenya, India, and Nepal. These surveys will be used to assess the distribution of eye disease among different sociodemographic groups, and to track attendance rates between groups in four major eye screening programmes. We gather data from 3,850 people in each country and use logistic regression to identify the groups that experience the worst access to community-based eye care services in each setting. We will use a secure, password protected android-based app to gather sociodemographic information. These data will be stored using state-of-the art security measures, complying with each country's data management legislation and UK law. Discussion This low-risk, embedded, pragmatic, observational data collection will enable eye screening programme managers to accurately identify which sociodemographic groups are facing the highest systematic barriers to accessing care at any point in time. This information will be used to inform the development of service improvements to improve equity.
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Affiliation(s)
- Luke N Allen
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Bakgaki Ratshaa
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Ari Ho-Foster
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Hillary Rono
- Peek Vision, Berkhamsted, UK
- Kitale County and Referral Hospital, Kitale, Kenya
| | - Abhiskek Roshan
- Nepal Netra Jyoti Sangh, Kathmandu, Nepal
- Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | - David Macleod
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Min Kim
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana Patricia Marques
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Nigel Bolster
- Peek Vision, Berkhamsted, UK
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Andrew Bastawrous
- Peek Vision, Berkhamsted, UK
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
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Shafi Abdurahman O, Last A, Macleod D, Habtamu E, Versteeg B, Dumessa G, Guye M, Nure R, Adugna D, Miecha H, Greenland K, Burton MJ. Trachoma risk factors in Oromia Region, Ethiopia. PLoS Negl Trop Dis 2023; 17:e0011679. [PMID: 37934731 PMCID: PMC10629622 DOI: 10.1371/journal.pntd.0011679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/21/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Trachoma, the leading infectious cause of blindness, is caused by the bacterium Chlamydia trachomatis (Ct). Despite enormous disease control efforts and encouraging progress, trachoma remains a significant public health problem in 44 countries. Ethiopia has the greatest burden of trachoma worldwide, however, robust data exploring transmission risk factors and the association between socio-economic status is lacking from some regions. This is the first study to investigate these factors in this South-Eastern region of Oromia, Ethiopia. METHODOLOGY/PRINCIPAL FINDINGS A total of 1211 individuals were enrolled from 247 households in Shashemene Rural district in Oromia Region between 11th April and 25th June 2018, of whom 628 (51.9%) were female and 526 (43.4%) were children aged 1-9 years. Three standardised ophthalmic nurses examined each participant for the presence of active trachoma using the WHO simplified trachoma grading system. Conjunctival swab samples were collected from the upper tarsal conjunctiva of the left eye of each participant. Ct was detected using quantitative PCR. Risk factor data were collected through structured interviews and direct observations. Clinical signs of trachomatous inflammation-follicular among children aged 1-9 (TF1-9) were observed in at least one eye of 106/526 (20.2%) and trachomatous inflammation-intense among children aged 1-9 (TI1-9) were observed in at least one eye of 10/526 (1.9%). We detected Ct by PCR in 23 individuals, of whom 18 (78.3%) were in children aged 1-9 years. Among the 106 children aged 1-9 years with TF, 12 (11.3%) were Ct PCR positive and among 20 children aged 1-9 years with TI, 4 (20.0%) were Ct PCR positive. In a multivariable model, adjusting for household clustering, active trachoma was associated with younger age, the poorest households (aOR = 2.56, 95% CI 1.21-5.51), presence of flies on the face (aOR = 2.87, 95% CI 1.69-6.46), and ocular discharge (aOR = 1.89, 95% CI 1.03-3.24). Pre-school children face washing more than once a day had lower odds of having active trachoma (aOR = 0.59, 95% CI 0.19-0.84). The same was true for washing children's clothing at least once per week (aOR = 0.27, 95% CI 0.33-1.02). CONCLUSION/SIGNIFICANCE Younger age, personal hygiene in this age group (presence of ocular and nasal discharges, infrequent washing of faces and clothing) and fly-eye contacts are potential risk factors for trachoma in this setting, suggesting that hygiene interventions and environmental improvements are required to suppress transmission to ensure sustained reduction in disease burden Further studies are needed to evaluate these interventions for trachoma control and elimination. Trachoma remains a disease associated with lower socio-economic status, emphasising the need for continued implementation of control measures in addition to poverty reduction interventions in this region.
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Affiliation(s)
- Oumer Shafi Abdurahman
- International Centre for Eye Health, Clinical Research Department, Faculty of Infectious and Tropical diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- The Fred Hollows Foundation, Addis Ababa, Ethiopia
| | - Anna Last
- International Centre for Eye Health, Clinical Research Department, Faculty of Infectious and Tropical diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David Macleod
- International Centre for Eye Health, Clinical Research Department, Faculty of Infectious and Tropical diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Esmael Habtamu
- International Centre for Eye Health, Clinical Research Department, Faculty of Infectious and Tropical diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bart Versteeg
- International Centre for Eye Health, Clinical Research Department, Faculty of Infectious and Tropical diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Meseret Guye
- The Fred Hollows Foundation, Addis Ababa, Ethiopia
| | - Rufia Nure
- The Fred Hollows Foundation, Addis Ababa, Ethiopia
| | - Dereje Adugna
- Oromia Regional Health Bureau, Addis Ababa, Ethiopia
| | - Hirpha Miecha
- Oromia Regional Health Bureau, Addis Ababa, Ethiopia
| | - Katie Greenland
- Environmental Health Group, Department for Disease Control, Faculty of Infectious and Tropical. Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Matthew J. Burton
- International Centre for Eye Health, Clinical Research Department, Faculty of Infectious and Tropical diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
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Allen LN, Nkomazana O, Mishra SK, Gichangi M, Macleod D, Ramke J, Bolster N, Marques AP, Rono H, Burton M, Kim M, Ratshaa B, Karanja S, Ho-Foster A, Bastawrous A. Improvement studies for equitable and evidence-based innovation: an overview of the 'IM-SEEN' model. Int J Equity Health 2023; 22:116. [PMID: 37330480 PMCID: PMC10276912 DOI: 10.1186/s12939-023-01915-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 05/11/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery. MAIN TEXT Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal. CONCLUSION There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice.
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Affiliation(s)
- Luke N Allen
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel St, London, WC1E 7HT, UK.
| | | | | | | | - David Macleod
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel St, London, WC1E 7HT, UK
| | - Jacqueline Ramke
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel St, London, WC1E 7HT, UK
| | | | - Ana Patricia Marques
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel St, London, WC1E 7HT, UK
| | - Hilary Rono
- Kitale Hospital and Peek Vision, Kitale, Kenya
| | - Matthew Burton
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel St, London, WC1E 7HT, UK
| | - Min Kim
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel St, London, WC1E 7HT, UK
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Tuft S, Evans J, Gordon I, Leck A, Stone N, Neal T, Macleod D, Kaye S, Burton MJ. Antimicrobial resistance in topical treatments for microbial keratitis: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e069338. [PMID: 36882242 PMCID: PMC10008341 DOI: 10.1136/bmjopen-2022-069338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/13/2023] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION There is evidence for increased resistance against the antimicrobials used to treat keratitis. This review aims to provide global and regional prevalence estimates of antimicrobial resistance in corneal isolates and the range of minimum inhibitory concentrations (MIC) with their associated resistance breakpoints. METHODS AND ANALYSIS We report this protocol following Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols guidelines. We will conduct an electronic bibliographic search in MEDLINE, EMBASE, Web of Science and the Cochrane Library. Eligible studies will report in any language data for the resistance or MIC for antimicrobials against bacterial, fungal or amoebic organisms isolated from suspected microbial keratitis. Studies that only report on viral keratitis will not be included. There will be no time restrictions on the date of publication. Screening for eligible studies, assessment of risk of bias and data extraction will be conducted by two reviewers independently, using predefined inclusion criteria and prepiloted data extraction forms. We will resolve disagreements between the reviewers by discussion and, if required, a third (senior) reviewer will arbitrate. We will assess the risk of bias using a tool validated in prevalence studies. The certainty of the evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation approach. Pooled proportion estimates will be calculated using a random-effects model. Heterogeneity will be assessed using the I2 statistic. We will explore differences between Global Burden of Disease regions and temporal trends. ETHICS APPROVAL AND DISSEMINATION Ethics approval is not required as this is a protocol for a systematic review of published data. The findings of this review will be published in an open-access, peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023331126.
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Affiliation(s)
- Stephen Tuft
- Cornea and External Disease Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Jennifer Evans
- Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Iris Gordon
- Department of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Astrid Leck
- Department of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Neil Stone
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Timothy Neal
- Department of Microbiology, Royal Liverpool University Hospital, Liverpool, UK
| | - David Macleod
- Department of Medical Statistics, LSHTM, London, London, UK
| | - Stephen Kaye
- Department of Eye and Vision Science, University of Liverpool, Liverpool, Merseyside, UK
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8
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Derrick T, Habtamu E, Tadesse Z, Callahan EK, Worku A, Gashaw B, Macleod D, Mabey DC, Holland MJ, Burton MJ. The conjunctival transcriptome in Ethiopians after trichiasis surgery: associations with the development of eyelid contour abnormalities and the effect of oral doxycycline treatment. Wellcome Open Res 2022; 4:130. [PMID: 37426632 PMCID: PMC10323279 DOI: 10.12688/wellcomeopenres.15419.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 07/31/2023] Open
Abstract
Background: Surgery to correct trichiasis is a key component of the World Health Organisation trachoma control strategy, however unfavourable outcomes such as eyelid contour abnormalities (ECA) following surgery are relatively common. This study aimed to understand the transcriptional changes associated with the early development of ECA and the impact of doxycycline, which has anti-inflammatory and anti-fibrotic properties, upon these transcription patterns. Methods: One thousand Ethiopians undergoing trichiasis surgery were enrolled in a randomised controlled trial following informed consent. Equal groups of randomly assigned individuals were orally administered with 100mg/day of doxycycline (n=499) or placebo (n=501) for 28 days. Conjunctival swabs were collected immediately prior to surgery and at one- and six-months post-surgery. 3' mRNA sequencing was performed on paired baseline and one-month samples from 48 individuals; 12 in each treatment/outcome group (Placebo-Good outcome, Placebo-Poor outcome, Doxycycline-Good outcome, Doxycycline-Poor outcome). qPCR validation was then performed for 46 genes of interest in 145 individuals who developed ECA at one month and 145 matched controls, using samples from baseline, one and six months. Results: All treatment/outcome groups upregulated genes associated with wound healing pathways at one month relative to baseline, however no individual differences were detected between groups. The summed expression of a highly coexpressed cluster of pro-fibrotic genes was higher in patients that developed ECA in the placebo group relative to controls. qPCR validation revealed that all genes in this cluster and a number of other pro-inflammatory genes were strongly associated with ECA, however these associations were not modulated by trial arm. Conclusions: The development of post-operative ECA is associated with overexpression of pro-inflammatory and pro-fibrotic genes including growth factors, matrix metalloproteinases, collagens and extracellular matrix proteins. There was no evidence that doxycycline modulated the association between gene expression and ECA.
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Affiliation(s)
- Tamsyn Derrick
- London School of Hygiene and Tropical Medicine, London, UK
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Esmael Habtamu
- London School of Hygiene and Tropical Medicine, London, UK
- The Carter Center, Addis Ababa, Ethiopia
| | | | | | - Abebaw Worku
- Amhara Regional Health Bureau, Bahirdar, Ethiopia
| | | | - David Macleod
- London School of Hygiene and Tropical Medicine, London, UK
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9
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Macleod D, Shanaube K, Skalland T, Limbada M, Mandla N, Bwalya J, Schaap A, Yang B, Donnell D, Piwowar-Manning E, Eshleman SH, Hoddinott G, Bond V, Moore A, Griffith S, Bock P, Ayles H, Fidler S, Hayes R, Floyd S. Viral suppression and self-reported ART adherence after 3 years of universal testing and treatment in the HPTN 071 (PopART) community-randomised trial in Zambia and South Africa: a cross-sectional analysis. Lancet HIV 2022; 9:e751-e759. [PMID: 36332652 PMCID: PMC9646982 DOI: 10.1016/s2352-3018(22)00237-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 07/25/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In 2014, UNAIDS set the target that 90% of individuals on antiretroviral therapy (ART) be virally suppressed. Here, we use data from the HPTN 071 (PopART) trial to report whether the introduction of universal testing and treatment has affected viral suppression or treatment adherence among individuals who self-reported they were taking ART, and identify risk factors for these outcomes. METHODS This was a cross-sectional study nested within the randomly selected population cohort of the PopART trial. The trial took place in 21 communities in Zambia and South Africa. Analyses included 3570 HIV-positive participants who were seen at the second follow-up visit in 2016-17 and who self-reported that they were currently taking ART. Viral suppression was defined as HIV RNA of less than 400 copies per mL from a blood sample collected during the cohort visit, and ART adherence was measured using self-reporting (reported as no missed pills in last 7 days). Prevalences of these outcomes were compared across three trial arms using a two-stage approach suitable for clustered data. Each arm consisted of seven communities, with one arm receiving a combination HIV prevention package including immediate ART initiation, one receiving a combination HIV prevention package excluding immediate ART initiation and one arm receving standard of care. Risk factors for each of the outcomes were assessed using logistic regression. FINDINGS Among the 3570 participants who self-reported that they were currently on ART, 416 (11·7%) of 3554 were not virally suppressed (16 were missing viral suppression status) and 345 (9·7%) of 3566 reported being non-adherent to ART (four were missing adherence status). The proportion not virally suppressed was higher in communities in South Africa (195 [16·4%] of 1191) than in Zambia (221 [9·4%] of 2363). There was no evidence that the prevalence of the outcomes differed between trial arms. There was evidence that men, younger individuals, individuals who reported participating in harmful alcohol use, and those who reported internalised stigma were more likely to be non-adherent, and not virally suppressed. INTERPRETATION The results assuaged concerns that early ART initiation in a universal testing and treatment setting could lead to reduced adherence and viral suppression. FUNDING US National Institute of Allergy and Infectious Diseases (which is a part of the National Institutes of Health), the International Initiative for Impact Evaluation with support from the Bill & Melinda Gates Foundation, US President's Emergency Plan for AIDS Relief, and Medical Research Council UK.
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Affiliation(s)
- David Macleod
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Kwame Shanaube
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | | | - Mohammed Limbada
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Nomtha Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Justin Bwalya
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ab Schaap
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Blia Yang
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Deborah Donnell
- HPTN Statistical and Data Management Centre, Seattle, WA, USA
| | | | - Susan H Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Virginia Bond
- Global Health and Development Department, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK; Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ayana Moore
- FHI 360, HIV Prevention Trials Network, Durham, NC, USA
| | - Sam Griffith
- FHI 360, HIV Prevention Trials Network, Durham, NC, USA
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Sarah Fidler
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Richard Hayes
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sian Floyd
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Probert WJM, Sauter R, Pickles M, Cori A, Bell-Mandla NF, Bwalya J, Abeler-Dörner L, Bock P, Donnell DJ, Floyd S, Macleod D, Piwowar-Manning E, Skalland T, Shanaube K, Wilson E, Yang B, Ayles H, Fidler S, Hayes RJ, Fraser C. Projected outcomes of universal testing and treatment in a generalised HIV epidemic in Zambia and South Africa (the HPTN 071 [PopART] trial): a modelling study. Lancet HIV 2022; 9:e771-e780. [PMID: 36332654 PMCID: PMC9646978 DOI: 10.1016/s2352-3018(22)00259-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The long-term impact of universal home-based testing and treatment as part of universal testing and treatment (UTT) on HIV incidence is unknown. We made projections using a detailed individual-based model of the effect of the intervention delivered in the HPTN 071 (PopART) cluster-randomised trial. METHODS In this modelling study, we fitted an individual-based model to the HIV epidemic and HIV care cascade in 21 high prevalence communities in Zambia and South Africa that were part of the PopART cluster-randomised trial (intervention period Nov 1, 2013, to Dec 31, 2017). The model represents coverage of home-based testing and counselling by age and sex, delivered as part of the trial, antiretroviral therapy (ART) uptake, and any changes in national guidelines on ART eligibility. In PopART, communities were randomly assigned to one of three arms: arm A received the full PopART intervention for all individuals who tested positive for HIV, arm B received the intervention with ART provided in accordance with national guidelines, and arm C received standard of care. We fitted the model to trial data twice using Approximate Bayesian Computation, once before data unblinding and then again after data unblinding. We compared projections of intervention impact with observed effects, and for four different scenarios of UTT up to Jan 1, 2030 in the study communities. FINDINGS Compared with standard of care, a 51% (95% credible interval 40-60) reduction in HIV incidence is projected if the trial intervention (arms A and B combined) is continued from 2020 to 2030, over and above a declining trend in HIV incidence under standard of care. INTERPRETATION A widespread and continued commitment to UTT via home-based testing and counselling can have a substantial effect on HIV incidence in high prevalence communities. FUNDING National Institute of Allergy and Infectious Diseases, US President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation, National Institute on Drug Abuse, and National Institute of Mental Health.
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Affiliation(s)
- William J M Probert
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK.
| | - Rafael Sauter
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Anne Cori
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Nomtha F Bell-Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Lucie Abeler-Dörner
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - David Macleod
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Ethan Wilson
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Blia Yang
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, University of Zambia, Lusaka, Zambia; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College London, London, UK; NIHR Imperial Biomedical Research Centre, London, UK
| | - Richard J Hayes
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Christophe Fraser
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
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11
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Allen LN, Mackinnon S, Gordon I, Blane D, Marques AP, Gichuhi S, Mwangi A, Burton MJ, Bolster N, Macleod D, Kim M, Ramke J, Bastawrous A. Performance and Resource Requirements of In-Person, Voice Call, and Automated Telephone-Based Socioeconomic Data Collection Modalities for Community-Based Health Programs: A Systematic Review. JAMA Netw Open 2022; 5:e2243883. [PMID: 36441550 PMCID: PMC9706363 DOI: 10.1001/jamanetworkopen.2022.43883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Gathering data on socioeconomic status (SES) is a prerequisite for health programs that aim to improve equity. There is a lack of evidence on which approaches offer the best combination of reliability, cost, and acceptability. OBJECTIVE To compare the performance of different approaches to gathering data on SES in community health programs. DATA SOURCES A search of the Cochrane Library, MEDLINE, Embase, Global Health, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and OpenGrey from 1999 to June 29, 2021, was conducted, with no language limits. Google Scholar was also searched and the reference lists of included articles were checked to identify further studies. The search was performed on June 29, 2021. STUDY SELECTION Any empirical study design was eligible if it compared 2 or more modalities to elicit SES data from the following 3 categories: in-person, voice call, or automated telephone-based systems. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened titles, abstracts, and full-text articles and extracted data. They also assessed the risk of bias using Cochrane tools and assessed the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. Findings were synthesized thematically without meta-analysis. MAIN OUTCOMES AND MEASURES Response rate, equivalence, time, costs, and acceptability to patients and health care professionals. RESULTS The searches returned 3943 records. The 11 included studies reported data on 14 036 individuals from 7 countries, collecting data on 11 socioeconomic domains using 2 or more of the following modes: in-person surveys, computer-assisted telephone interviews (CATIs), and 2 types of automated data collection: interactive voice response calls (IVRs) and web surveys. Response rates were greater than 80% for all modes except IVRs. Equivalence was high across all modes (Cohen κ > 0.5). There were insufficient data to make robust time and cost comparisons. Patients reported high levels of acceptability providing data via IVRs, web surveys, and CATIs. CONCLUSIONS AND RELEVANCE Selecting an appropriate and cost-effective modality to elicit SES data is an important first step toward advancing equitable effective service coverage. This systematic review did not identify evidence that remote and automated data collection modes differed from human-led and in-person approaches in terms of reliability, cost, or acceptability.
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Affiliation(s)
- Luke N. Allen
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Iris Gordon
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David Blane
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Ana Patricia Marques
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | | | - Matthew J. Burton
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nigel Bolster
- Peek Vision, Berkhamsted, United Kingdom
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David Macleod
- International Statistics & Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Min Kim
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jacqueline Ramke
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Andrew Bastawrous
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
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12
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Allen LN, Ratshaa B, Macleod D, Bolster N, Burton M, Kim M, Bastawrous A, Ho-Foster A, Chroston H, Nkomazana O. Protocol for an automated, pragmatic, embedded, adaptive randomised controlled trial: behavioural economics-informed mobile phone-based reminder messages to improve clinic attendance in a Botswanan school-based vision screening programme. Trials 2022; 23:656. [PMID: 35971156 PMCID: PMC9377141 DOI: 10.1186/s13063-022-06519-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinic non-attendance rates are high across the African continent. Emerging evidence suggests that phone-based reminder messages could make a small but important contribution to reducing non-attendance. We will use behavioural economics principles to develop an SMS and voice reminder message to improve attendance rates in a school-based eye screening programme in Botswana. METHODS We will test a new theory-informed SMS and voice reminder message in a national school-based eye screening programme in Botswana. The control will be the standard SMS message used to remind parents/guardians to bring their child for ophthalmic assessment. All messages will be sent twice. The primary outcome is attendance for ophthalmic assessment. We will use an automated adaptive approach, starting with a 1:1 allocation ratio. DISCUSSION As far as we are aware, only one other study has used behavioural economics to inform the development of reminder messages to be deployed in an African healthcare setting. Our study will use an adaptive trial design, embedded in a national screening programme. Our approach can be used to trial other forms of reminder message in the future. TRIAL REGISTRATION ISRCTN 96528723 . Registered on 5 January 2022.
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Affiliation(s)
| | | | | | - Nigel Bolster
- LSHTM, Keppel St, London, WC1E 7HT, UK.,Peek Vision, Berkhamsted, UK
| | | | - Min Kim
- LSHTM, Keppel St, London, WC1E 7HT, UK
| | - Andrew Bastawrous
- LSHTM, Keppel St, London, WC1E 7HT, UK.,Peek Vision, Berkhamsted, UK
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13
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Hargreaves JR, Pliakas T, Hoddinott G, Mainga T, Mubekapi‐Musadaidzwa C, Donnell D, Wilson E, Piwowar‐Manning E, Agyei Y, Bell‐Mandla NF, Dunbar R, Schaap A, Macleod D, Floyd S, Bock P, Fidler S, Seeley J, Stangl A, Bond V, Ayles H, Hayes RJ. The association between HIV stigma and HIV incidence in the context of universal testing and treatment: analysis of data from the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc 2022; 25 Suppl 1:e25931. [PMID: 35818869 PMCID: PMC9274206 DOI: 10.1002/jia2.25931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/03/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION To investigate the association between individual and community-level measures of HIV stigma and HIV incidence within the 21 communities participating in the HPTN (071) PopART trial in Zambia and South Africa. METHODS Secondary analysis of data from a population-based cohort followed-up over 36 months between 2013 and 2018. The outcome was rate of incident HIV infection among individuals who were HIV negative at cohort entry. Individual-level exposures, measured in a random sample of all participants, were: (1) perception of stigma in the community, (2) perception of stigma in health settings and (3) fear and judgement towards people living with HIV. Individual-level analyses were conducted with adjusted, individual-level Poisson regression. Community-level HIV stigma exposures drew on data reported by people living with HIV, health workers and community members. We used linear regression to explore the association between HIV stigma and community-level HIV incidence. RESULTS Among 8172 individuals who were HIV negative and answered individual-level stigma questions at enrolment to the cohort, there was no evidence of a statistically significant association between any domain of HIV stigma and risk of incident HIV infection. Among the full cohort of 26,110 individuals among whom HIV incidence was measured, there was no evidence that community-level HIV incidence was associated with any domain of HIV stigma. CONCLUSIONS HIV stigma is often cited as a barrier to the effectiveness of HIV prevention programming. However, in the setting for the HPTN 071 "PopART trial," measured stigma alone was not associated with the risk of HIV infection.
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Affiliation(s)
- James R. Hargreaves
- Department of Public Health, Environments and Society, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Tila Mainga
- Zambart, School of Public HealthUniversity of ZambiaLusakaZambia
| | - Constance Mubekapi‐Musadaidzwa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | | | - Ethan Wilson
- Fred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | | | - Yaw Agyei
- Johns Hopkins UniversitySchool of MedicineBaltimoreMarylandUSA
| | - Nomtha F. Bell‐Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Ab Schaap
- Zambart, School of Public HealthUniversity of ZambiaLusakaZambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Sarah Fidler
- Department of Medicine, Imperial College NIHR BRCImperial College LondonLondonUK
| | - Janet Seeley
- Department of Global Health and Development, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Anne Stangl
- International Center for Research on WomenWashingtonDCUSA
- Hera SolutionsBaltimoreMarylandUSA
| | - Virginia Bond
- Zambart, School of Public HealthUniversity of ZambiaLusakaZambia
- Department of Global Health and Development, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- Zambart, School of Public HealthUniversity of ZambiaLusakaZambia
- Department of Clinical Research, Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Richard J. Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
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14
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Robinson A, Gomes LRDO, Abdurahman OS, Alemayehu W, Shuka G, Melese E, Guye M, Legesse D, Elias E, Temam K, Koro KH, Adugna D, Seife F, Aga MA, Sarah V, Lambert SM, Walker SL, Habtamu E, Solomon AW, Last A, Macleod D, Burton MJ, Logan JG. Evaluation of the efficacy of insecticide-treated scarves to protect children from the trachoma vector Musca sorbens (Diptera: Muscidae): A phase II randomised controlled trial in Oromia, Ethiopia. EClinicalMedicine 2022; 49:101487. [PMID: 35747196 PMCID: PMC9189873 DOI: 10.1016/j.eclinm.2022.101487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/05/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The eye-seeking fly Musca sorbens can act as a vector for ocular Chlamydia trachomatis, causing trachoma, yet there has been very little research on control measures. We investigated whether insect repellent products, specifically insecticide-treated clothing, could provide personal protection to the user from eye-seeking flies. METHODS We first conducted a series of phase I laboratory studies to inform our choice of field intervention. We then conducted a phase II randomised controlled trial testing the efficacy of permethrin-treated scarves (PTS) in reducing fly-face contact in Oromia, Ethiopia. Children aged 4-10 years in full health and with no known adverse reactions to permethrin or other insecticides were allocated to either arm using restricted randomisation. Intervention arm children wore Insect Shield® versatile wraps (as PTS) for 28 days. The primary outcomes, fly-eye, -nose and -mouth contact, were assessed on the first day (0/30/60/180 minutes), on day 7 and on day 28. All participants present per timepoint were included in analyses. This trial was registered with ClinicalTrials.gov (NCT03813069). FINDINGS Participants were recruited to the field trial between 29/10/2019 and 01/11/2019, 58 were randomised to test or control arm. More fly (-eye, -nose and -mouth) contacts were observed in the PTS arm at baseline. After adjusting for baseline contact rates, across all timepoints there was a 35% decrease in fly-eye contacts in the PTS relative to control arm (rate ratio [RR] 0.65, 95% CI 0.52-0.83). Similar cross-timepoint reductions were seen for fly-nose and fly-mouth contacts (RR 0.69, 95% CI 0.51-0.92 and RR 0.79, 95% CI 0.62-1.01, respectively). All children were included on day 0. Two in the control arm were absent on day 7, one left the study and four were excluded from analysis at day 28. No adverse events occurred in the trial. INTERPRETATION Musca sorbens flies are sufficiently repelled by PTS to reduce fly-eye contacts for the wearer, thus possibly reducing the risk of trachoma transmission. Permethrin-treated scarves may therefore an alternative to insecticide space spraying for protection from these flies. FUNDING Wellcome Trust.
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Affiliation(s)
- Ailie Robinson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Correspondence to: Dr Ailie Robinson, Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Laura Reis de Oliveira Gomes
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oumer Shafi Abdurahman
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Wondu Alemayehu
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
| | - Gemeda Shuka
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
| | - Ewunetu Melese
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
| | - Meseret Guye
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
| | - Demitu Legesse
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
| | - Eden Elias
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
| | - Kedir Temam
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
| | - Korso Hirpo Koro
- The Fred Hollows Foundation, P.O. Box 6307, Addis Ababa, Ethiopia
| | - Dereje Adugna
- Oromia Regional Health Bureau, Addis Ababa, Ethiopia
| | - Fikre Seife
- The Ethiopian Federal Ministry of Health, Disease Prevention and Control Directorate, Addis Ababa, Ethiopia
| | | | - Virginia Sarah
- Global Partnerships Executive, The Fred Hollows Foundation, 12-15 Crawford Mews, York Street, London W1H1LX
| | - Saba M. Lambert
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Stephen L. Walker
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Esmael Habtamu
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Anthony W. Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Avenue Appia 20, 1202 Genève, Switzerland
| | - Anna Last
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Matthew J. Burton
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- National Institute for Health Research Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - James G. Logan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Hoffman JJ, Yadav R, Sanyam SD, Chaudhary P, Roshan A, Singh SK, Singh SK, Mishra SK, Arunga S, Hu VH, Macleod D, Leck A, Burton MJ. Topical Chlorhexidine 0.2% versus Topical Natamycin 5% for the Treatment of Fungal Keratitis in Nepal: A Randomized Controlled Noninferiority Trial. Ophthalmology 2022; 129:530-541. [PMID: 34896126 PMCID: PMC9037000 DOI: 10.1016/j.ophtha.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 11/01/2022] Open
Abstract
PURPOSE To investigate if topical chlorhexidine 0.2%, which is low cost and easy to formulate, is noninferior to topical natamycin 5% for the treatment of filamentous fungal keratitis. DESIGN Randomized controlled, single-masked, noninferiority clinical trial. PARTICIPANTS Adults attending a tertiary-level ophthalmic hospital in Nepal with filamentous fungal infection confirmed on smear or confocal microscopy. METHODS Participants were randomly allocated to receive topical chlorhexidine 0.2% or topical natamycin 5%. Primary analysis (intention-to-treat) was by linear regression, using baseline logarithm of the minimum angle of resolution (logMAR) best spectacle-corrected visual acuity (BSCVA) and treatment arm as prespecified covariates. Mixed fungal-bacterial infections were excluded from the primary analysis but included in secondary analyses and secondary safety-related outcomes. The noninferiority margin was 0.15 logMAR. This trial was registered with ISRCTN, number ISRCTN14332621. MAIN OUTCOME MEASURES The primary outcome measure was BSCVA at 3 months. Secondary outcome measures included perforation or therapeutic penetrating keratoplasty by 90 days. RESULTS Between June 3, 2019, and November 9, 2020, 354 eligible participants were enrolled and randomly assigned: 178 to chlorhexidine and 176 to natamycin. Primary outcome data were available for 153 and 151 of the chlorhexidine and natamycin groups, respectively. Of these, mixed bacterial-fungal infections were found in 20 cases (12/153 chlorhexidine, 8/151 natamycin) and excluded from the primary analysis. Therefore, 284 patients were assessed for the primary outcome (141 chlorhexidine, 143 natamycin). We did not find evidence to suggest chlorhexidine was noninferior to natamycin and in fact found strong evidence to suggest that natamycin-treated participants had significantly better 3-month BSCVA than chlorhexidine-treated participants, after adjusting for baseline BSCVA (regression coefficient, -0.30; 95% confidence interval [CI], -0.42 to -0.18; P < 0.001). There were more perforations and emergency corneal grafts in the chlorhexidine arm (24/175, 13.7%) than in the natamycin arm (10/173, 5.8%; P = 0.018, mixed infections included), whereas natamycin-treated cases were less likely to perforate or require an emergency corneal graft, after adjusting for baseline ulcer depth (odds ratio, 0.34; 95% CI, 0.15-0.79; P = 0.013). CONCLUSIONS Treatment with natamycin is associated with significantly better visual acuity, with fewer adverse events, compared with treatment with chlorhexidine. Natamycin remains the preferred first-line monotherapy treatment for filamentous fungal keratitis.
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Affiliation(s)
- Jeremy J Hoffman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; Sagarmatha Choudhary Eye Hospital, Lahan, Nepal; Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
| | - Reena Yadav
- Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | | | | | | | | | | | | | - Simon Arunga
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; Mbarara University of Science and Technology, Mbarara, Uganda
| | - Victor H Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Macleod
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
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16
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Allen LN, Mackinnon S, Gordon I, Blane D, Marques AP, Gichuhi S, Mwangi A, Burton MJ, Bolster N, Macleod D, Kim M, Ramke J, Bastawrous A. Performance and resource requirements of in-person versus voice call versus automated telephone-based socioeconomic data collection modalities for community-based health programmes: a systematic review protocol. BMJ Open 2022; 12:e057410. [PMID: 35428640 PMCID: PMC9014069 DOI: 10.1136/bmjopen-2021-057410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Gathering data on socioeconomic status (SES) is a prerequisite for any health programme that aims to assess and improve the equitable distribution of its outcomes. Many different modalities can be used to collect SES data, ranging from (1) face-to-face elicitation, to (2) telephone-administered questionnaires, to (3) automated text message-based systems. The relative costs and perceived benefits to patients and providers of these different data collection approaches is unknown. This protocol is for a systematic review that aims to compare the resource requirements, performance characteristics, and acceptability to participants and service providers of these three approaches to collect SES data from those enrolled in health programmes. METHODS AND ANALYSIS An information specialist will conduct searches on the Cochrane Library, MEDLINE, Embase, Global Health, ClinicalTrials.gov, the WHO ICTRP and OpenGrey. All databases will be searched from 1999 to present with no language limits used. We will also search Google Scholar and check the reference lists of relevant articles for further potentially eligible studies. Any empirical study design will be eligible if it compares two or more modalities to elicit SES data from the following three; in-person, voice call, or automated phone-based systems. Two reviewers will independently screen titles, abstracts and full-text articles; and complete data extraction. For each study, we will extract data on the modality characteristics, primary outcomes (response rate and equivalence) and secondary outcomes (time, costs and acceptability to patients and providers). We will synthesise findings thematically without meta-analysis. ETHICS AND DISSEMINATION Ethical approval is not required, as our review will include published and publicly accessible data. This review is part of a project to improve equitable access to eye care services in low-ioncome and middle-income countries. However, the findings will be useful to policy-makers and programme managers in a range of health settings and non-health settings. We will publish our findings in a peer-reviewed journal and develop an accessible summary of results for website posting and stakeholder meetings. PROSPERO REGISTRATION NUMBER CRD42021251959.
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Affiliation(s)
- Luke Nelson Allen
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Shona Mackinnon
- Institute of health and wellbeing, University of Glasgow, Glasgow, UK
| | - Iris Gordon
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - David Blane
- Institute of health and wellbeing, University of Glasgow, Glasgow, UK
| | - Ana Patricia Marques
- London School of Hygiene and Tropical Medicine International Centre for Eye Health, London, UK
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | | | - Matthew J Burton
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Nigel Bolster
- London School of Hygiene and Tropical Medicine International Centre for Eye Health, London, UK
- Peek Vision, London, UK
| | - David Macleod
- London School of Hygiene and Tropical Medicine International Centre for Eye Health, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | - Min Kim
- London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Jacqueline Ramke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew Bastawrous
- London School of Hygiene and Tropical Medicine International Centre for Eye Health, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
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Philippin H, Macleod D, Matayan E, Gazzard G, Shah P, Makupa WU, Burton MJ. Selective laser trabeculoplasty for glaucoma in sub-Saharan Africa - Author's reply. Lancet Glob Health 2022; 10:e335. [PMID: 35180415 DOI: 10.1016/s2214-109x(21)00589-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/07/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Heiko Philippin
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Eye Centre, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - David Macleod
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Einoti Matayan
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Gus Gazzard
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust-University College London Institute of Ophthalmology, London, UK; University College London Institute of Ophthalmology, London, UK
| | - Peter Shah
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; University College London Institute of Ophthalmology, London, UK; Birmingham Institute for Glaucoma Research, Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, UK; Centre for Health and Social Care Improvement, University of Wolverhampton, Wolverhampton, UK
| | - William U Makupa
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Matthew J Burton
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust-University College London Institute of Ophthalmology, London, UK
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Hoffman JJ, Yadav R, Sanyam SD, Chaudhary P, Roshan A, Singh SK, Arunga S, Hu VH, Macleod D, Leck A, Burton MJ. Microbial Keratitis in Nepal: Predicting the Microbial Aetiology from Clinical Features. J Fungi (Basel) 2022; 8:jof8020201. [PMID: 35205955 PMCID: PMC8879647 DOI: 10.3390/jof8020201] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
Fungal corneal infection (keratitis) is a common clinical problem in South Asia. However, it is often challenging to distinguish this from other aetiologies, such as bacteria or acanthamoeba. In this prospective study, we investigated clinical and epidemiological features that can predict the microbial aetiology of microbial keratitis in Nepal. We recruited patients presenting with keratitis to a tertiary eye hospital in lowland eastern Nepal between June 2019 and November 2020. A structured assessment, including demographics, history, and clinical signs, was carried out. The aetiology was investigated with in vivo confocal microscopy and corneal scrape for microscopy and culture. A predictor score was developed using odds ratios calculated to predict aetiology from features. A fungal cause was identified in 482/642 (75.1%) of cases, which increased to 532/642 (82.9%) when including mixed infections. Unusually, dematiaceous fungi accounted for half of the culture-positive cases (50.6%). Serrated infiltrate margins, patent nasolacrimal duct, raised corneal slough, and organic trauma were independently associated with fungal keratitis (p < 0.01). These four features were combined in a predictor score. The probability of fungal keratitis was 30.1% if one feature was present, increasing to 96.3% if all four were present. Whilst microbiological diagnosis is the "gold standard" to determine the aetiology of an infection, certain clinical signs can help direct the clinician to find a presumptive infectious cause, allowing appropriate treatment to be started without delay. Additionally, this study identified dematiaceous fungi, specifically Curvularia spp., as the main causative agent for fungal keratitis in this region. This novel finding warrants further research to understand potential implications and any trends over time.
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Affiliation(s)
- Jeremy J. Hoffman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.A.); (V.H.H.); (D.M.); (A.L.); (M.J.B.)
- Correspondence:
| | - Reena Yadav
- Sagarmatha Choudhary Eye Hospital, Lahan 56502, Nepal; (R.Y.); (S.D.S.); (P.C.); (A.R.); (S.K.S.)
| | - Sandip Das Sanyam
- Sagarmatha Choudhary Eye Hospital, Lahan 56502, Nepal; (R.Y.); (S.D.S.); (P.C.); (A.R.); (S.K.S.)
| | - Pankaj Chaudhary
- Sagarmatha Choudhary Eye Hospital, Lahan 56502, Nepal; (R.Y.); (S.D.S.); (P.C.); (A.R.); (S.K.S.)
| | - Abhishek Roshan
- Sagarmatha Choudhary Eye Hospital, Lahan 56502, Nepal; (R.Y.); (S.D.S.); (P.C.); (A.R.); (S.K.S.)
| | - Sanjay Kumar Singh
- Sagarmatha Choudhary Eye Hospital, Lahan 56502, Nepal; (R.Y.); (S.D.S.); (P.C.); (A.R.); (S.K.S.)
| | - Simon Arunga
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.A.); (V.H.H.); (D.M.); (A.L.); (M.J.B.)
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara P.O. Box 1410, Uganda
| | - Victor H. Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.A.); (V.H.H.); (D.M.); (A.L.); (M.J.B.)
| | - David Macleod
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.A.); (V.H.H.); (D.M.); (A.L.); (M.J.B.)
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.A.); (V.H.H.); (D.M.); (A.L.); (M.J.B.)
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.A.); (V.H.H.); (D.M.); (A.L.); (M.J.B.)
- National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London EC1V 9EL, UK
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Limbada M, Bwalya C, Macleod D, Shibwela O, Floyd S, Nzara D, Situmbeko V, Hayes R, Fidler S, Ayles H. Acceptability and Preferences of Two Different Community Models of ART Delivery in a High Prevalence Urban Setting in Zambia: Cluster-Randomized Trial, Nested in the HPTN 071 (PopART) Study. AIDS Behav 2022; 26:328-338. [PMID: 34304330 PMCID: PMC8813709 DOI: 10.1007/s10461-021-03385-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 11/29/2022]
Abstract
Community delivery of Antiretroviral therapy (ART) is a novel innovation to increase sustainable ART coverage for People living with HIV (PLHIV) in resource limited settings. Within a nested cluster-randomised sub-study in two urban communities that participated in the HPTN 071 (PopART) trial in Zambia we investigated individual acceptability and preferences for ART delivery models. Stable PLHIV were enrolled in a cluster-randomized trial of three different models of ART: Facility-based delivery (SoC), Home-based delivery (HBD) and Adherence clubs (AC). Consenting individuals were asked to express their stated preference for ART delivery options. Those assigned to the community models of ART delivery arms could choose ("revealed preference") between the assigned arm and facility-based delivery. In total 2489 (99.6%) eligible individuals consented to the study and 95.6% chose community models of ART delivery rather than facility-based delivery when offered a choice. When asked to state their preference of model of ART delivery, 67.6% did not state a preference of one model over another, 22.8% stated a preference for HBD, 5.0% and 4.6% stated a preference for AC and SoC, respectively. Offering PLHIV choices of community models of ART delivery is feasible and acceptable with majority expressing HBD as their stated preferred option.
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Affiliation(s)
- Mohammed Limbada
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Chiti Bwalya
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Osborn Shibwela
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Diana Nzara
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Vasty Situmbeko
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College, United Kingdom and Imperial College NIHR BRC, London, UK
| | - Helen Ayles
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - the HPTN 071 (PopART) Study Team
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Imperial College, United Kingdom and Imperial College NIHR BRC, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Hoffman JJ, Yadav R, Das Sanyam S, Chaudhary P, Roshan A, Singh SK, Mishra SK, Arunga S, Hu VH, Macleod D, Leck A, Burton MJ. Delay in accessing definitive care for patients with microbial keratitis in Nepal. Front Med (Lausanne) 2022; 9:915293. [PMID: 35935768 PMCID: PMC9354956 DOI: 10.3389/fmed.2022.915293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this study was to describe the health-seeking journey for patients with microbial keratitis (MK) in Nepal and identify factors associated with delay. Methods Prospective cohort study where MK patients attending a large, tertiary-referral eye hospital in south-eastern Nepal between June 2019 and November 2020 were recruited. We collected demographic details, clinical history, and examination findings. Care-seeking journey details were captured including places attended, number of journeys, time from symptom onset, and costs. We compared "direct" with "indirect" presenters, analyzing for predictors of delay. Results We enrolled 643 patients with MK. The majority (96%) self-referred. "Direct" attenders accounted for only 23.6% (152/643) of patients, the majority of "indirect" patients initially presented to a pharmacy (255/491). Over half (328/643) of all cases presented after at least 7 days. The total cost of care increased with increasing numbers of facilities visited (p < 0.001). Those living furthest away were least likely to present directly (p < 0.001). Factors independently associated with delayed presentation included distance >50 km from the eye hospital [aOR 5.760 (95% CI 1.829-18.14, p = 0.003)], previous antifungal use [aOR 4.706 (95% CI 3.139-5.360)], and two or more previous journeys [aOR 1.442 (95% CI 1.111-3.255)]. Conclusions Most patients visited at least one facility prior to our institution, with time to presentation and costs increasing with the number of prior journeys. Distance to the eye hospital is a significant barrier to prompt, direct presentation. Based on these findings, improving access to eye care services, strengthening referral networks and encouraging early appropriate treatment are recommended to reduce delay, ultimately improving clinical outcomes.
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Affiliation(s)
- Jeremy J Hoffman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | - Reena Yadav
- Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | | | | | | | | | | | - Simon Arunga
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Victor H Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Macleod
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
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Limbada M, Macleod D, Situmbeko V, Muhau E, Shibwela O, Chiti B, Floyd S, Schaap AJ, Hayes R, Fidler S, Ayles H. Rates of viral suppression in a cohort of people with stable HIV from two community models of ART delivery versus facility-based HIV care in Lusaka, Zambia: a cluster-randomised, non-inferiority trial nested in the HPTN 071 (PopART) trial. Lancet HIV 2022; 9:e13-e23. [PMID: 34843674 PMCID: PMC8716341 DOI: 10.1016/s2352-3018(21)00242-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 08/20/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Non-facility-based antiretroviral therapy (ART) delivery for people with stable HIV might increase sustainable ART coverage in low-income and middle-income countries. Within the HPTN 071 (PopART) trial, two interventions, home-based delivery (HBD) and adherence clubs (AC), which included groups of 15-30 participants who met at a communal venue, were compared with standard of care (SoC). In this trial we looked at the effectiveness and feasibility of these alternative models of care. Specifically, this trial aimed to assess whether these models of care had similar virological suppression to that of SoC 12 months after enrolment. METHODS This was a three-arm, cluster-randomised, non-inferiority trial, done in two urban communities in Lusaka, Zambia included in the HPTN 071 trial. The two communities were split into zones, which were randomly assigned (1:1:1) to the three treatment strategies: 35 zones to the SoC group, 35 zones to the HBD group, and 34 zones to the AC group. ART and adherence support were delivered once every 3 months at home for the HBD group, in groups of 15-30 people in the AC group, or in the clinic for the SoC group. Adults with HIV who were receiving first-line ART for at least 6 months, virally suppressed using national HIV guidelines in the last 12 months, had no other health conditions requiring the clinicians attention, live in the study catchment area, and provided written informed consent, were eligible for inclusion. The primary endpoint was viral suppression at 12 months (with a 6 month final measurement window [ie, 9-15 months]), defined as less than 1000 HIV RNA copies per mL, with a non-inferiority margin of 5%. FINDINGS Between May 5 and Dec 19, 2017, 9900 individuals were screened for inclusion, of whom 2489 (25·1%) participants were enrolled into the trial: 781 (31%) in the SoC group, 852 (34%) in the HBD group, and 856 (34%) in the AC group. A higher proportion of participants had viral load measurements in the primary outcome window in the HBD (581 [61%]of 852 participants) and AC (485 [57%] of 856 participants) groups than in the SoC (390 [50%] of 781 patients) group (p=0·0021). Of the 1096 missing observations, 152 (13·8%) were attributable to either deaths (25 [16%] participants), relocations (37 [24%] participants), or lost to follow-up (90 [59%]); 690 (63·0%) participants had viral load results outside the window period; and 254 (23·2%) did not have a viral load result. The prevalence of viral suppression was estimated to be 98·3% (95% CI 96·6 to 99·7) in the SoC group, 98·7% (97·5 to 99·6) in the HBD group, and 99·2% (98·4 to 99·8) in the AC group. This gave an estimated risk difference of 0·3% (95% CI -1·5 to 2·4) for the HBD group compared with the SoC group and 0·9% (-0·8 to 2·8) for the AC group compared with the SoC group. There was strong evidence (p<0·0001) that both community ART models were non-inferior to the SoC group (p<0·0001). INTERPRETATION Community models of ART delivery were as effective as facility-based care in terms of viral suppression. FUNDING National Institute of Allergy and Infectious Diseases, The International Initiative for Impact Evaluation (3ie), the Bill & Melinda Gates Foundation, National Institute on Drug Abuse, National Institute of Mental Health, and President's Emergency Plan for AIDS Relief.
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Affiliation(s)
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | | | - Albertus J Schaap
- Zambart, Lusaka, Zambia; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial college National Institute for Health Research Biomedical Research Centre, London, UK
| | - Helen Ayles
- Zambart, Lusaka, Zambia; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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22
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Brizel D, Mowery Y, Zhen W, Chan J, Macleod D, Yom S. A Phase 1-2 Trial of Concurrent Radiation Therapy, Cisplatin and BMX-001 in Locally Advanced Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Philippin H, Matayan E, Knoll KM, Macha E, Mbishi S, Makupa A, Matsinhe C, da Gama V, Monjane M, Ncheda AJ, Mulobuana FA, Muna E, Fopoussi N, Gazzard G, Marques AP, Shah P, Macleod D, Makupa WU, Burton MJ. Selective laser trabeculoplasty versus 0·5% timolol eye drops for the treatment of glaucoma in Tanzania: a randomised controlled trial. Lancet Glob Health 2021; 9:e1589-e1599. [PMID: 34655547 PMCID: PMC8526362 DOI: 10.1016/s2214-109x(21)00348-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Glaucoma is a major cause of sight loss worldwide, with the highest regional prevalence and incidence reported in Africa. The most common low-cost treatment used to control glaucoma is long-term timolol eye drops. However, low adherence is a major challenge. We aimed to investigate whether selective laser trabeculoplasty (SLT) was superior to timolol eye drops for controlling intraocular pressure (IOP) in patients with open-angle glaucoma. METHODS We did a two-arm, parallel-group, single-masked randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Moshi, Tanzania. Eligible participants (aged ≥18 years) had open-angle glaucoma and an IOP above 21 mm Hg, and did not have asthma or a history of glaucoma surgery or laser. Participants were randomly assigned (1:1) to receive 0·5% timolol eye drops to administer twice daily or to receive SLT. The primary outcome was the proportion of eyes from both groups with treatment success, defined as an IOP below or equal to target pressure according to glaucoma severity, at 12 months following randomisation. Re-explanation of eye drop application or a repeat SLT was permitted once. The primary analysis was by modified intention-to-treat, excluding participants lost to follow-up, using logistic regression; generalised estimating equations were used to adjust for the correlation between eyes. This trial was registered with the Pan African Clinical Trials Registry, number PACTR201508001235339. FINDINGS 840 patients were screened for eligibility, of whom 201 (24%) participants (382 eligible eyes) were enrolled between Aug 31, 2015, and May 12, 2017. 100 (50%) participants (191 eyes) were randomly assigned to the timolol group and 101 (50%; 191 eyes) to the SLT group. After 1 year, 339 (89%) of 382 eyes were analysed. Treatment was successful in 55 (31%) of 176 eyes in the timolol group (16 [29%] of 55 eyes required repeat administration counselling) and in 99 (61%) of 163 eyes in the SLT group (33 [33%] of 99 eyes required repeat SLT; odds ratio 3·37 [95% CI 1·96-5·80]; p<0·0001). Adverse events (mostly unrelated to ocular events) occurred in ten (10%) participants in the timolol group and in eight (8%) participants in the SLT group (p=0·61). INTERPRETATION SLT was superior to timolol eye drops for managing patients with open-angle high-pressure glaucoma for 1 year in Tanzania. SLT has the potential to transform the management of glaucoma in sub-Saharan Africa, even where the prevalence of advanced glaucoma is high. FUNDING Christian Blind Mission, Seeing is Believing Innovation Fund, and the Wellcome Trust. TRANSLATIONS For the Kiswahili, French and Portuguese translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Heiko Philippin
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Eye Centre, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Einoti Matayan
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Karin M Knoll
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Edith Macha
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Sia Mbishi
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Andrew Makupa
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Cristóvão Matsinhe
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Provincial Hospital of Pemba, Pemba, Mozambique
| | - Vasco da Gama
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Hospital Central de Quelimane, Quelimane, Mozambique
| | - Mario Monjane
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Awum Joyce Ncheda
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Presbyterian Eye Hospital, Bafoussam, Cameroon
| | | | - Elisante Muna
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Nelly Fopoussi
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Cameroon Baptist Convention Health Services, Douala, Cameroon
| | - Gus Gazzard
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust-University College London Institute of Ophthalmology, London, UK; University College London Institute of Ophthalmology, London, UK
| | - Ana Patricia Marques
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Shah
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; University College London Institute of Ophthalmology, London, UK; Birmingham Institute for Glaucoma Research, Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, UK; Centre for Health and Social Care Improvement, University of Wolverhampton, Wolverhampton, UK
| | - David Macleod
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - William U Makupa
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Matthew J Burton
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust-University College London Institute of Ophthalmology, London, UK
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Rono H, Bastawrous A, Macleod D, Mamboleo R, Bunywera C, Wanjala E, Gichuhi S, Burton MJ. Effectiveness of an mHealth system on access to eye health services in Kenya: a cluster-randomised controlled trial. Lancet Digit Health 2021; 3:e414-e424. [PMID: 34167763 PMCID: PMC8239618 DOI: 10.1016/s2589-7500(21)00083-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/14/2021] [Accepted: 04/27/2021] [Indexed: 01/19/2023]
Abstract
Background There is limited access to eye health services in many low-income and middle-income populations. We aimed to assess the effectiveness in increasing service utilisation of the Peek Community Eye Health (Peek CEH) system, a smartphone-based referral system comprising decision support algorithms (Peek Community Screening app), SMS reminders, and real-time reporting. Methods In this cluster-randomised controlled trial of eye health in Kenya, community unit clusters were defined as one health centre and its catchment population. Clusters were randomly allocated (1:1) to receive Peek CEH and referral (intervention group) or standard care via periodic health centre-based outreach clinics and onward referral (control group). Individuals in the intervention group were assessed at home by screeners and those referred were asked to present for triage assessment in a central location. They received regular SMS reminders. In both groups, community sensitisation was done followed by a triage clinic at the cluster health centre 4 weeks after sensitisation. During triage, individuals in both groups were assessed and treated and, if necessary, referred to a specific hospital. Individuals in the intervention group received further SMS reminders. The primary outcome was the mean attendance rate (the number of people per 10 000 population) at triage of those with confirmed eye conditions, as assessed at 4 weeks after sensitisation in the intention-to-treat population. We estimated the intervention effect using a Student's t-test on cluster-level rates. This trial is registered with Pan African Clinical Trial Registry, number 201807329096632. Findings Between Nov 26, 2018, and June 7, 2019, of the 85 community units in Trans Nzoia County, Kenya, 49 were excluded. We randomly allocated 18 community units each to the intervention group (68 348 individuals) and the control group (60 243 individuals). 9387 individuals from the intervention group and 3070 from the control group attended triage assessment. The mean attendance rate at triage by individuals with eye problems was 1429 (92% CI 1228–1629) in the intervention group and 522 (418–625) in the control group (rate difference 906 per 10 000 [95% CI 689–1124; p<0·0001]). Interpretation The Peek CEH system increased primary care attendance by people with eye problems compared with standard approaches, indicating the potential of this mobile health package to increase service uptake and guide appropriate task sharing. Funding The Queen Elizabeth Diamond Jubilee Trust and Wellcome Trust.
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Affiliation(s)
- Hillary Rono
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK; Kitale County Referral and Teaching Hospital, Kitale, Kenya; Peek Vision, Berkhamsted, Hertfordshire, UK.
| | - Andrew Bastawrous
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK; Peek Vision, Berkhamsted, Hertfordshire, UK
| | - David Macleod
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Stephen Gichuhi
- Department of Ophthalmology, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK; Moorfields Eye Hospital NHS Trust, London, UK
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Viljoen L, Mainga T, Casper R, Mubekapi-Musadaidzwa C, Wademan DT, Bond VA, Pliakas T, Bwalya C, Stangl A, Phiri M, Yang B, Shanaube K, Bock P, Fidler S, Hayes R, Ayles H, Hargreaves JR, Hoddinott G, Seeley J, Donnell D, Floyd S, Mandla N, Bwalya J, Sabapathy K, Eshleman SH, Macleod D, Moore A, Vermund SH, Hauck K, Shanaube K. Community-based health workers implementing universal access to HIV testing and treatment: lessons from South Africa and Zambia-HPTN 071 (PopART). Health Policy Plan 2021; 36:881-890. [PMID: 33963387 PMCID: PMC8227454 DOI: 10.1093/heapol/czab019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 01/20/2023] Open
Abstract
The global expansion of HIV testing, prevention and treatment services is necessary to achieve HIV epidemic control and promote individual and population health benefits for people living with HIV (PLHIV) in sub-Saharan Africa. Community-based health workers (CHWs) could play a key role in supporting implementation at scale. In the HPTN 071 (PopART) trial in Zambia and South Africa, a cadre of 737 study-specific CHWs, working closely with government-employed CHW, were deployed to deliver a ‘universal’ door-to-door HIV prevention package, including an annual offer of HIV testing and referral services for all households in 14 study communities. We conducted a process evaluation using qualitative and quantitative data collected during the trial (2013–2018) to document the implementation of the CHW intervention in practice. We focused on the recruitment, retention, training and support of CHWs, as they delivered study-specific services. We then used these descriptions to: (i) analyse the fidelity to design of the delivery of the intervention package, and (ii) suggest key insights for the transferability of the intervention to other settings. The data included baseline quantitative data collected with the study-specific CHWs (2014–2018); and qualitative data from key informant interviews with study management (n = 91), observations of CHW training events (n = 12) and annual observations of and group discussions (GD) with intervention staff (n = 68). We show that it was feasible for newly recruited CHWs to implement the PopART intervention with good fidelity, supporting the interpretation of the trial outcome findings. This was despite some challenges in managing service quality and CHW retention in the early years of the programme. We suggest that by prioritizing the adoption of key elements of the in-home HIV services delivery intervention model—including training, emotional support to workers, monitoring and appropriate remuneration for CHWs—these services could be successfully transferred to new settings.
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Affiliation(s)
- Lario Viljoen
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa.,Department of Sociology and Social Anthropology, Stellenbosch University, Stellenbosch, South Africa
| | - Tila Mainga
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Rozanne Casper
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Constance Mubekapi-Musadaidzwa
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Dillon T Wademan
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Virginia A Bond
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia.,Global Health and Development Department, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Chiti Bwalya
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Anne Stangl
- International Center for Research on Women, Washington, DC, USA.,Hera Solutions, Baltimore, MD, USA
| | - Mwelwa Phiri
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Blia Yang
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Kwame Shanaube
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Peter Bock
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College NIHR BRC, Imperial College London, UK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia.,Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - James R Hargreaves
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
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Limbada M, Zijlstra G, Macleod D, Ayles H, Fidler S. A systematic review of the effectiveness of non- health facility based care delivery of antiretroviral therapy for people living with HIV in sub-Saharan Africa measured by viral suppression, mortality and retention on ART. BMC Public Health 2021; 21:1110. [PMID: 34112135 PMCID: PMC8194040 DOI: 10.1186/s12889-021-11053-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Alternative models for sustainable antiretroviral treatment (ART) delivery are necessary to meet the increasing demand to maintain population-wide ART for all people living with HIV (PLHIV) in sub-Saharan Africa. We undertook a review of published literature comparing health facility-based care (HFBC) with non-health facility based care (nHFBC) models of ART delivery in terms of health outcomes; viral suppression, loss to follow-up, retention and mortality. METHODS We conducted a systematic search of Medline, Embase and Global Health databases from 2010 onwards. UNAIDS reports, WHO guidelines and abstracts from conferences were reviewed. All studies measuring at least one of the following outcomes, viral load suppression, loss-to-follow-up (LTFU) and mortality were included. Data were extracted, and a descriptive analysis was performed. Risk of bias assessment was done for all studies. Pooled estimates of the risk difference (for viral suppression) and hazard ratio (for mortality) were made using random-effects meta-analysis. RESULTS Of 3082 non-duplicate records, 193 were eligible for full text screening of which 21 published papers met the criteria for inclusion. The pooled risk difference of viral load suppression amongst 4 RCTs showed no evidence of a difference in viral suppression (VS) between nHFBC and HFBC with an overall estimated risk difference of 1% [95% CI -1, 4%]. The pooled hazard ratio of mortality amongst 2 RCTs and 4 observational cohort studies showed no evidence of a difference in mortality between nHFBC and HFBC with an overall estimated hazard ratio of 1.01 [95% CI 0.88, 1.16]. Fifteen studies contained data on LTFU and 13 studies on retention. Although no formal quantitative analysis was performed on these outcomes due to the very different definitions between papers, it was observed that the outcomes appeared similar between HFBC and nHFBC. CONCLUSIONS Review of current literature demonstrates comparable outcomes for nHFBC compared to HFBC ART delivery programmes in terms of viral suppression, retention and mortality. PROSPERO NUMBER CRD42018088194 .
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Affiliation(s)
- Mohammed Limbada
- Zambart House, PO Box 50697, UNZA-Ridgeway Campus, Lusaka, Zambia.
| | | | - David Macleod
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- Zambart House, PO Box 50697, UNZA-Ridgeway Campus, Lusaka, Zambia
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial college NIHR BRC, London, UK
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Mushumbusi E, Buchan J, Mactaggart I, Macleod D, Foster A. A Systematic Review of the Proportion of Blindness in the Population 50 Years and Older from Total Population-Based Surveys of Blindness and Visual Impairment. Ophthalmic Epidemiol 2021; 29:164-170. [PMID: 33944649 DOI: 10.1080/09286586.2021.1918176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: Epidemiological data is essential for planning; however, all-age population-based surveys are resource intensive. Rapid Assessment of Cataract Surgical Services methodology was developed in India in 1995 and subsequently promoted by the World Health Organisation for use worldwide. The commonly used Rapid Assessment of Avoidable Blindness (RAAB) evolved from this in 2005, constraining surveys to populations aged 50 or more based on the report 'The Epidemiology of Blindness in Nepal' (SEVA, 1988), where 78.7% of blindness occurred in people aged 50+. The purpose of this study is to examine whether more recent total-population-based surveys continue to find a similar proportion of blindness in the population aged 50+.Methods:A systematic literature review identified all population-based surveys of blindness published 1996-2017. Data extraction was undertaken by two independent researchers and compared.Results:The proportions of blindness (presenting visual acuity (PVA) <3/60) and moderate/severe visual impairment (MSVI) (PVA <6/18-3/60) from total population-based surveys in people aged 50+ ranged from 90% (Mali, 1996) to 45.8% (South Korea, 2015); the mean proportions across all surveys were 73.1% (95% CI, 60.4-85.8%) for blindness, and 73.8% (95% CI, 54.8-92.8) for MSVI. No trend over time or association with GDP was identified.Conclusion:This systematic literature review supports the rationale for constraining surveys to the population aged 50+ as this will greatly reduce sample size but still include a high proportion of total cases of blindness; paucity of total population-based surveys highlights the ongoing need for RAAB in service planning internationally.
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Affiliation(s)
- Edmund Mushumbusi
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - John Buchan
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Islay Mactaggart
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Allen Foster
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
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Macleod D, Wass V, Laird S, McKeown J. GP lead medical student visits to primary schools can provide a valuable learning experience for both students and pupils. Educ Prim Care 2021; 32:351-355. [PMID: 33890554 DOI: 10.1080/14739879.2021.1915709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: A key clinical skill for undergraduate medical students is communication with children, yet it is becoming increasingly difficult for medical schools to provide sufficient experience within a secondary care setting. One potential solution to this is to develop innovative ways of involving local schools.Aim: To demonstrate what was learned from a pilot school visit and show how this was developed into a successful programme.Method: As part of their GP-based Foundations of Primary Care course, medical students were allocated to local primary schools in their tutorial groups led by their GP tutors. They developed and delivered health promotion activities that were appropriate for school pupils. Review of the visit identified areas of improvement which were used to redesign the programme. Surveys were conducted after the subsequent visit to assess the response of medical students, school pupils and teachers.Learning outcomes: Medical students gained experience in communicating and interacting with school-aged children, and developed teaching and team working skills. School pupils reported change in their health-related knowledge and behaviour and the visits introduced them to the medical profession at a young age. The visits were well received by the teachers who valued the medical students' input.Conclusions: Building on the learning from the pilot school visit, a successful programme was developed that was challenging but ultimately enhanced medical student learning and brought significant benefits for the school pupils. Future developments include the potential to expand the topics taught and developing training in teaching for medical students.
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Affiliation(s)
- David Macleod
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Val Wass
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Shirley Laird
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - John McKeown
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Shanaube K, Macleod D, Chaila MJ, Mackworth-Young C, Hoddinott G, Schaap A, Floyd S, Bock P, Hayes R, Fidler S, Ayles H. HIV Care Cascade Among Adolescents in a "Test and Treat" Community-Based Intervention: HPTN 071 (PopART) for Youth Study. J Adolesc Health 2021; 68:719-727. [PMID: 33059959 PMCID: PMC8022105 DOI: 10.1016/j.jadohealth.2020.07.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The PopART for Youth (P-ART-Y) study was nested within the HPTN 071 (PopART) trial, a three-arm community randomized trial in 21 communities in Zambia and South Africa. The P-ART-Y study evaluated the acceptability and uptake of a combination HIV prevention package among young people. We report on the HIV care cascade for adolescents aged 10-19 years from 14 communities receiving the full HIV prevention package in Zambia and South Africa. METHODS Adolescents were offered participation in the PopART intervention, which included universal home-based HIV testing, linkage to care, antiretroviral therapy (ART) adherence, and other services. Data were collected from September 2016 to December 2017, covering the third round (R3) of the intervention. RESULTS We enumerated (listed) 128,241 adolescents (Zambia: 95,295 and South Africa: 32,946). Of the adolescents offered HIV testing, 81.9% accepted in Zambia and 70.3% in South Africa. Knowledge of HIV status was higher among older adolescents and increased from 31.4% before R3 to 88.3% at the end of R3 in Zambia and from 28.3% to 79.5% in South Africa. Overall, there were 1,710 (1.9%) adolescents identified as living with HIV by the end of R3 (515 new diagnoses and 1,195 self-reported). Of the new diagnoses, 335 (65.0%) were girls aged 15-19 years. The median time to initiate ART was 5 months. ART coverage before and after R3 increased from 61.3% to 78.7% in Zambia and from 65.6% to 87.8% in South Africa, with boys having higher uptake than girls in both countries. CONCLUSIONS The PopART intervention substantially increased coverage toward the first and second UNAIDS 90-90-90 targets in adolescents.
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Affiliation(s)
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Constance Mackworth-Young
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ab Schaap
- Zambart, Lusaka, Zambia,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Faculty of Medicine, Department of Infectious Disease, Imperial College, London, United Kingdom
| | - Helen Ayles
- Zambart, Lusaka, Zambia,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
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30
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Ehrlich JR, Ramke J, Macleod D, Burn H, Lee CN, Zhang JH, Waldock W, Swenor BK, Gordon I, Congdon N, Burton M, Evans JR. Association between vision impairment and mortality: a systematic review and meta-analysis. Lancet Glob Health 2021; 9:e418-e430. [PMID: 33607015 PMCID: PMC7966688 DOI: 10.1016/s2214-109x(20)30549-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/30/2020] [Accepted: 12/16/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The number of individuals with vision impairment worldwide is increasing because of an ageing population. We aimed to systematically identify studies describing the association between vision impairment and mortality, and to assess the association between vision impairment and all-cause mortality. METHODS For this systematic review and meta-analysis, we searched MEDLINE (Ovid), Embase, and Global Health database on Feb 1, 2020, for studies published in English between database inception and Feb 1, 2020. We included prospective and retrospective cohort studies that measured the association between vision impairment and all-cause mortality in people aged 40 years or older who were followed up for 1 year or more. In a protocol amendment, we also included randomised controlled trials that met the same criteria as for cohort studies, in which the association between visual impairment and mortality was independent of the study intervention. Studies that did not report age-adjusted mortality data, or that focused only on populations with specific health conditions were excluded. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. We graded the overall certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations framework. We did a random-effects meta-analysis to calculate pooled maximally adjusted hazard ratios (HRs) for all-cause mortality for individuals with a visual acuity of <6/12 versus those with ≥6/12; <6/18 versus those with ≥6/18; <6/60 versus those with ≥6/18; and <6/60 versus those with ≥6/60. FINDINGS Our searches identified 3845 articles, of which 28 studies, representing 30 cohorts (446 088 participants) from 12 countries, were included in the systematic review. The meta-analysis included 17 studies, representing 18 cohorts (47 998 participants). There was variability in the methods used to assess and report vision impairment. Pooled HRs for all-cause mortality were 1·29 (95% CI 1·20-1·39) for visual acuity <6/12 versus ≥6/12, with low heterogeneity between studies (n=15; τ2=0·01, I2=31·46%); 1·43 (1·22-1·68) for visual acuity <6/18 versus ≥6/18, with low heterogeneity between studies (n=2; τ2=0·0, I2=0·0%); 1·89 (1·45-2·47) for visual acuity <6/60 versus ≥6/18 (n=1); and 1·02 (0·79-1·32) for visual acuity <6/60 versus ≥6/60 (n=2; τ2=0·02, I2=25·04%). Three studies received an assessment of low risk of bias across all six domains, and six studies had a high risk of bias in one or more domains. Effect sizes were greater for studies that used best-corrected visual acuity compared with those that used presenting visual acuity as the vision assessment method (p=0·0055), but the effect sizes did not vary in terms of risk of bias, study design, or participant-level factors (ie, age). We judged the evidence to be of moderate certainty. INTERPRETATION The hazard for all-cause mortality was higher in people with vision impairment compared with those that had normal vision or mild vision impairment, and the magnitude of this effect increased with more severe vision impairment. These findings have implications for promoting healthy longevity and achieving the Sustainable Development Goals. FUNDING Wellcome Trust, Commonwealth Scholarship Commission, National Institutes of Health, Research to Prevent Blindness, the Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity, National Institute for Health Research, Moorfields Biomedical Research Centre, Sightsavers, the Fred Hollows Foundation, the Seva Foundation, the British Council for the Prevention of Blindness, and Christian Blind Mission.
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Affiliation(s)
- Joshua R Ehrlich
- Department of Ophthalmology and Visual Sciences, and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK; School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - David Macleod
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK; International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen Burn
- Department of Ophthalmology, Stoke Mandeville Hospital, Aylesbury, UK
| | - Chan Ning Lee
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK; St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Justine H Zhang
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK; Manchester Royal Eye Hospital, Manchester, UK
| | | | - Bonnielin K Swenor
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Iris Gordon
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Nathan Congdon
- Queen's University Belfast, Belfast, UK; Zhongshan Ophthalmic Center, Guangzhou, China
| | - Matthew Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK; Moorfields Eye Hospital, London, UK
| | - Jennifer R Evans
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
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31
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Dean WH, Buchan J, Gichuhi S, Philippin H, Arunga S, Mukome A, Admassu F, Lewis K, Makupa W, Otiti J, Kim MJ, Macleod D, Cook C, Burton MJ. Simulation-based surgical education for glaucoma versus conventional training alone: the GLAucoma Simulated Surgery (GLASS) trial. A multicentre, multicountry, randomised controlled, investigator-masked educational intervention efficacy trial in Kenya, South Africa, Tanzania, Uganda and Zimbabwe. Br J Ophthalmol 2021; 106:863-869. [PMID: 33495158 PMCID: PMC9132848 DOI: 10.1136/bjophthalmol-2020-318049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/05/2020] [Accepted: 01/04/2021] [Indexed: 12/26/2022]
Abstract
Background/Aim Glaucoma accounts for 8% of global blindness and surgery remains an important treatment. We aimed to determine the impact of adding simulation-based surgical education for glaucoma. Methods We designed a randomised controlled, parallel-group trial. Those assessing outcomes were masked to group assignment. Fifty-one trainee ophthalmologists from six university training institutions in sub-Saharan Africa were enrolled by inclusion criteria of having performed no surgical trabeculectomies and were randomised. Those randomised to the control group received no placebo intervention, but received the training intervention after the initial 12-month follow-up period. The intervention was an intense simulation-based surgical training course over 1 week. The primary outcome measure was overall simulation surgical competency at 3 months. Results Twenty-five were assigned to the intervention group and 26 to the control group, with 2 dropouts from the intervention group. Forty-nine were included in the final intention-to-treat analysis. Surgical competence at baseline was comparable between the arms. This increased to 30.4 (76.1%) and 9.8 (24.4%) for the intervention and the control group, respectively, 3 months after the training intervention for the intervention group, a difference of 20.6 points (95% CI 18.3 to 22.9, p<0.001). At 1 year, the mean surgical competency score of the intervention arm participants was 28.6 (71.5%), compared with 11.6 (29.0%) for the control (difference 17.0, 95% CI 14.8 to 19.4, p<0.001). Conclusion These results support the pursuit of financial, advocacy and research investments to establish simulation surgery training units and courses including instruction, feedback, deliberate practice and reflection with outcome measurement to enable trainee glaucoma surgeons to engage in intense simulation training for glaucoma surgery. Trial registration number PACTR201803002159198.
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Affiliation(s)
- William H Dean
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK .,Ophthalmology, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - John Buchan
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen Gichuhi
- Ophthalmology, University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Heiko Philippin
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.,Eye Centre, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Baden-Württemberg, Germany
| | - Simon Arunga
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.,Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Agrippa Mukome
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Fisseha Admassu
- Department of Ophthalmology, University of Gondar, Gondar, Ethiopia
| | - Karinya Lewis
- Ophthalmology, Salisbury Hospital NHS Foundation Trust, Salisbury, Wiltshire, UK
| | - William Makupa
- Ophthalmology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - Juliet Otiti
- Ophthalmology, Makerere University Faculty of Medicine, Kampala, Uganda
| | - Min J Kim
- Tropical Epidemiology Group, Faculty of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- Tropical Epidemiology Group, Faculty of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Colin Cook
- Ophthalmology, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Matthew J Burton
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.,Moorfields Eye Hospital NHS Foundation Trust, London, UK
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32
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Limbada M, Bwalya C, Macleod D, Floyd S, Schaap A, Situmbeko V, Hayes R, Fidler S, Ayles H. A comparison of different community models of antiretroviral therapy delivery with the standard of care among stable HIV+ patients: rationale and design of a non-inferiority cluster randomized trial, nested in the HPTN 071 (PopART) study. Trials 2021; 22:52. [PMID: 33430928 PMCID: PMC7802215 DOI: 10.1186/s13063-020-05010-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/29/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Following the World Health Organization's (WHO) 2015 guidelines recommending initiation of antiretroviral therapy (ART) irrespective of CD4 count for all people living with HIV (PLHIV), many countries in sub-Saharan Africa have adopted this strategy to reach epidemic control. As the number of PLHIV on ART rises, maintenance of viral suppression on ART for over 90% of PLHIV remains a challenge to government health systems in resource-limited high HIV burden settings. Non facility-based antiretroviral therapy (ART) delivery for stable HIV+ patients may increase sustainable ART coverage in resource-limited settings. Within the HPTN 071 (PopART) trial, two models, home-based delivery (HBD) or adherence clubs (AC), were offered to assess whether they achieved similar viral load suppression (VLS) to standard of care (SoC). In this paper, we describe the trial design and discuss the methodological issues and challenges. METHODS A three-arm cluster randomized non-inferiority trial, nested in two urban HPTN 071 trial communities in Zambia, randomly allocated 104 zones to SoC (35), HBD (35), or AC (34). ART and adherence support were delivered 3-monthly at home (HBD), adherence clubs (AC), or clinic (SoC). Adult HIV+ patients defined as "stable" on ART were eligible for inclusion. The primary endpoint was the proportion of PLHIV with virological suppression (≤ 1000 copies HIV RNA/ml) at 12 months (± 3months) after study entry across all three arms. Viral load measurement was done at the routine government laboratories in accordance with national guidelines, annually. The study was powered to determine if either of the community-based interventions would yield a viral suppression rate drop compared to SoC of no more than 5% in its absolute value. Both community-based interventions were delivered by community HIV providers (CHiPs). An additional qualitative study using observations, interviews with PLHIV, and FGDs with community HIV providers was nested in this study to complement the quantitative data. DISCUSSION This trial was designed to provide rigorous randomized evidence of safety and efficacy of non-facility-based delivery of ART for stable PLHIV in high-burden resource-limited settings. This trial will inform policy regarding best practices and what is needed to strengthen scale-up of differentiated models of ART delivery in resource-limited settings. TRIAL REGISTRATION ClinicalTrials.gov NCT03025165 . Registered on 19 January 2017.
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Affiliation(s)
- Mohammed Limbada
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia.
| | - Chiti Bwalya
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ab Schaap
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Vasty Situmbeko
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial College NIHR BRC, London, UK
| | - Helen Ayles
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Hargreaves JR, Pliakas T, Hoddinott G, Mainga T, Mubekapi-Musadaidzwa C, Donnell D, Piwowar-Manning E, Agyei Y, Mandla NF, Dunbar R, Macleod D, Floyd S, Bock P, Fidler S, Hayes RJ, Seeley J, Stangl A, Bond V, Ayles H. HIV Stigma and Viral Suppression Among People Living With HIV in the Context of Universal Test and Treat: Analysis of Data From the HPTN 071 (PopART) Trial in Zambia and South Africa. J Acquir Immune Defic Syndr 2020; 85:561-570. [PMID: 32991336 PMCID: PMC7654947 DOI: 10.1097/qai.0000000000002504] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/05/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized. SETTING Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial. METHODS We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding. RESULTS Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression. CONCLUSION Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.
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Affiliation(s)
- James R. Hargreaves
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Tila Mainga
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Constance Mubekapi-Musadaidzwa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Yaw Agyei
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nomhle F. Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - David Macleod
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sarah Fidler
- Imperial College NIHR BRC, Imperial College London, London, United Kingdom; and
| | - Richard J. Hayes
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anne Stangl
- International Center for Research on Women, Washington, DC
| | - Virginia Bond
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Helen Ayles
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
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Hoffman JJ, Yadav R, Das Sanyam S, Chaudhary P, Roshan A, Singh SK, Arunga S, Matayan E, Macleod D, Weiss HA, Leck A, Hu V, Burton MJ. Topical chlorhexidine 0.2% versus topical natamycin 5% for fungal keratitis in Nepal: rationale and design of a randomised controlled non-inferiority trial. BMJ Open 2020; 10:e038066. [PMID: 32998924 PMCID: PMC7528427 DOI: 10.1136/bmjopen-2020-038066] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Fungal infections of the cornea, fungal keratitis (FK), are challenging to treat. Current topical antifungals are not always effective and are often unavailable, particularly in low-income and middle-income countries where most cases occur. Topical natamycin 5% is usually first-line treatment, however, even when treated intensively, infections may progress to perforation of the eye in around a quarter of cases. Alternative antifungal medications are needed to treat this blinding disease.Chlorhexidine is an antiseptic agent with antibacterial and antifungal properties. Previous pilot studies suggest that topical chlorhexidine 0.2% compares favourably with topical natamycin. Full-scale randomised controlled trials (RCTs) of topical chlorhexidine 0.2% are warranted to answer this question definitively. METHODS AND ANALYSIS We will test the hypothesis that topical chlorhexidine 0.2% is non-inferior to topical natamycin 5% in a two-arm, single-masked RCT. Participants are adults with FK presenting to a tertiary ophthalmic hospital in Nepal. Baseline assessment includes history, examination, photography, in vivo confocal microscopy and cornea scrapes for microbiology. Participants will be randomised to alternative topical antifungal treatments (topical chlorhexidine 0.2% and topical natamycin 5%; 1:1 ratio, 2-6 random block size). Patients are reviewed at day 2, day 7 (with reculture), day 14, day 21, month 2 and month 3. The primary outcome is the best spectacle corrected visual acuity (BSCVA) at 3 months. Primary analysis (intention to treat) will be by linear regression, with treatment arm and baseline BSCVA prespecified covariates. Secondary outcomes include epithelial healing time, scar/infiltrate size, ulcer depth, hypopyon size, perforation and/or therapeutic penetrating keratoplasty (corneal transplant), positive reculture rate (day 7) and quality of life (EuroQol-5 dimensions, WHO/PBD-VF20, WHOQOL-BREF). ETHICS AND DISSEMINATION The Nepal Health Research Council, the Nepal Department of Drug Administration and the London School of Hygiene and Tropical Medicine ethics committee have approved the trial. The results will be presented at local and international meetings and submitted to peer-reviewed journals for publication. TRIAL REGISTRATION NUMBER ISRCTN14332621; pre-results.
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Affiliation(s)
- Jeremy John Hoffman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Cornea Department, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | - Reena Yadav
- Cornea Department, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | | | - Pankaj Chaudhary
- Cornea Department, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | - Abhishek Roshan
- Cornea Department, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | | | - Simon Arunga
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Mbarara University of Science and Technology Faculty of Medicine, Mbarara, Uganda
| | - Einoti Matayan
- Department of Ophthalmology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - David Macleod
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen Anne Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Victor Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of External Eye Disease, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Dow N, Wass V, Macleod D, Muirhead L, McKeown J. 'GP Live'- recorded General Practice consultations as a learning tool for junior medical students faced with the COVID-19 pandemic restrictions. Educ Prim Care 2020; 31:377-381. [PMID: 32842902 DOI: 10.1080/14739879.2020.1812440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND First year medical students value doctor and patient contact. However, it can be challenging to achieve positive exposure to primary care on a large scale. The COVID-19 pandemic has placed even greater pressure on placing students in General Practice (GP). AIM To assess the feasibility and acceptability of showing Year 1 medical students authentic recorded consultations between GPs and patients, and then explore what they gained from this. METHOD Using Panopto® Video Platform, we pre-recorded real Primary Care consultations, with patient and GP consent, which were then processed securely using the University of Aberdeen server. These were shown to all Year 1 medical students who immediately debriefed these consultations in small groups with a GP tutor. Subsequently two focus groups were held with 11 students to evaluate what they had learnt. LEARNING OUTCOMES The consultations were easy to record and play during the teaching session, although there were some issues with sound quality. All students in the focus groups enjoyed the experience. They gained new knowledge about the skills of GPs, and recognised GPs as positive role models. Students were able to identify a variety of communication and consultation skills used by the GP, which reinforced their teaching on these delivered elsewhere in the course. CONCLUSION Using pre-recorded consultations as a teaching tool is reproducible, time-efficient and beneficial to students. We propose that this model of using authentic 'live' interactions between GPs and patients represents a valuable undergraduate educational opportunity and could be utilised by medical schools internationally.
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Affiliation(s)
- Naomi Dow
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen , Aberdeen, UK
| | - Val Wass
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen , Aberdeen, UK
| | - David Macleod
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen , Aberdeen, UK
| | - Laura Muirhead
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen , Aberdeen, UK
| | - John McKeown
- General Practice and Community Medical Education, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen , Aberdeen, UK
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Mwangi N, Bascaran C, Ng'ang'a M, Ramke J, Kipturgo M, Gichuhi S, Kim M, Macleod D, Moorman C, Muraguri D, Gakuo E, Muthami L, Foster A. Feasibility of a cluster randomized controlled trial on the effectiveness of peer-led health education interventions to increase uptake of retinal examination for diabetic retinopathy in Kirinyaga, Kenya: a pilot trial. Pilot Feasibility Stud 2020; 6:102. [PMID: 32695434 PMCID: PMC7364632 DOI: 10.1186/s40814-020-00644-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 07/06/2020] [Indexed: 01/18/2023] Open
Abstract
Background People living with diabetes can reduce their risk of vision loss from diabetic retinopathy by attending screening, which enables early detection and timely treatment. The aim of this pilot trial was to assess the feasibility of a full-scale cluster randomized controlled trial of an intervention to increase uptake of retinal examination in this population, as delivered within existing community-based diabetes support groups (DSGs). Methods All 16 DSGs in Kirinyaga county were invited to participate in the study. The first two groups recruited took part in the pilot trial. DSG members who met the eligibility criteria were recruited before the groups that were randomized to the two arms. In the intervention group, two peer educators were trained to deliver monthly DSG-based eye health education and individual telephone reminders to attend screening. The control group continued with usual DSG practice which is monthly meetings without eye health education. The recruitment team and outcome assessors were masked to the allocation. We documented the study processes to ascertain the feasibility, acceptability, and potential effectiveness of the intervention. Feasibility was assessed in terms of clarity of study procedures, recruitment and retention rates, level of acceptability, and rates of uptake of eye examination. We set the target feasibility criteria for continuation to the main study to be recruitment of 50 participants in the trial, 80% monthly follow-up rates for individuals, and no attrition of clusters. Results Of the 122 DSG members who were assessed for eligibility, 104 were recruited and followed up: 51 (intervention) and 53 (control) arm. The study procedures were well understood and easy to apply. We learnt the DSG meeting days were the best opportunities for recruitment. The study had a high acceptance rate (100% for clusters, 95% for participants) and high follow-up and retention rate (100% of those recruited). All clusters and participants were analysed. We observed that the rate of incidence of eye exam was about 6 times higher in the intervention arm as compared to the control arm. No adverse unexpected events were reported in either arm. Conclusions The study is feasible and acceptable in the study population. The results support the development of a full-scale cluster RCT, as the success criteria for the pilot were met. Trial registration Pan African Clinical Trials Registry PACTR201707002430195 Registered on 25 July 2017.
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Affiliation(s)
- Nyawira Mwangi
- Kenya Medical Training College, Nairobi, Kenya.,London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | - Min Kim
- London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Esbon Gakuo
- Kerugoya County Referral Hospital, Kerugoya, Kenya
| | | | - Allen Foster
- London School of Hygiene and Tropical Medicine, London, UK
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Versteeg B, Vasileva H, Houghton J, Last A, Shafi Abdurahman O, Sarah V, Macleod D, Solomon AW, Holland MJ, Thomson N, Burton MJ. Viability PCR shows that non-ocular surfaces could contribute to transmission of Chlamydia trachomatis infection in trachoma. PLoS Negl Trop Dis 2020; 14:e0008449. [PMID: 32667914 PMCID: PMC7384675 DOI: 10.1371/journal.pntd.0008449] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/27/2020] [Accepted: 06/03/2020] [Indexed: 11/24/2022] Open
Abstract
Background The presence of Chlamydia trachomatis (Ct) DNA at non-ocular sites suggests that these sites may represent plausible routes of Ct transmission in trachoma. However, qPCR cannot discriminate between DNA from viable and non-viable bacteria. Here we use a propodium monoazide based viability PCR to investigate how long Ct remains viable at non-ocular sites under laboratory-controlled conditions. Methods Cultured Ct stocks (strain A2497) were diluted to final concentrations of 1000, 100, 10 and 1 omcB copies/μL and applied to plastic, woven mat, cotton cloth and pig skin. Swabs were then systemically collected from each surface and tested for the presence Ct DNA using qPCR. If Ct DNA was recovered, Ct viability was assessed over time by spiking multiple areas of the same surface type with the same final concentrations. Swabs were collected from each surface at 0, 2, 4, 6, 8 and 24 hours after spiking. Viability PCR was used to determine Ct viability at each timepoint. Results We were able to detect Ct DNA on all surfaces except the woven mat. Total Ct DNA remained detectable and stable over 24 hours for all concentrations applied to plastic, pig skin and cotton cloth. The amount of viable Ct decreased over time. For plastic and skin surfaces, only those where concentrations of 100 or 1000 omcB copies/μL were applied still had viable loads detectable after 24 hours. Cotton cloth showed a more rapid decrease and only those where concentrations of 1000 omcB copies/μL were applied still had viable DNA detectable after 24 hours. Conclusion Plastic, cotton cloth and skin may contribute to transmission of the Ct strains that cause trachoma, by acting as sites where reservoirs of bacteria are deposited and later collected and transferred mechanically into previously uninfected eyes. Trachoma elimination efforts are hampered by limited understanding of Ct transmission routes. We have recently demonstrated the presence of Ct DNA at non-ocular sites in individuals living in households in Ethiopia where at least one resident had an ocular Ct infection detectable by quantitative PCR (qPCR). Ct DNA was most frequently detected on faces, hands and clothing, being found in such locations in 10–16% of samples tested. However, qPCR cannot discriminate between DNA from viable and non-viable organisms, and potentially misinform our understanding of Ct transmission routes. In this study, we used a propidium monoazide based viability PCR to investigate how long Ct remains viable on non-ocular sites by spiking different surfaces including pig skin, plastic and cotton cloth. These surfaces mimic non-ocular sites previously found to be positive for Ct DNA using standard qPCR. The results of our study show that viable Ct DNA could be recovered from plastic, cotton cloth and skin surfaces for up to 24 hours suggesting that these surfaces a role in ocular Ct transmission.
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Affiliation(s)
- Bart Versteeg
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Hristina Vasileva
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Joanna Houghton
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anna Last
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Oumer Shafi Abdurahman
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- The Fred Hollows Foundation, Addis Ababa, Ethiopia
| | | | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anthony W. Solomon
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Martin J. Holland
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nicholas Thomson
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Parasites and Microbes, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - Matthew J. Burton
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Moorfields Eye Hospital, London, United Kingdom
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Ehrlich JR, Ramke J, Macleod D, Swenor BK, Burn H, Lee CN, Waldock WJ, Zhang JH, Gordon I, Congdon N, Burton M, Evans JR. Association between vision impairment and mortality: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e037556. [PMID: 32565478 PMCID: PMC7311038 DOI: 10.1136/bmjopen-2020-037556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/30/2020] [Accepted: 05/22/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Due to growth and ageing of the world's population, the number of individuals worldwide with vision impairment (VI) and blindness is projected to increase rapidly over the coming decades. VI and blindness are an important cause of years lived with disability. However, the association of VI and blindness with mortality, including the risk of bias in published studies and certainty of the evidence, has not been adequately studied in an up-to-date systematic review and meta-analysis. METHODS AND ANALYSIS The planned systematic review and meta-analysis will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases, including MEDLINE Ovid, Embase Ovid and Global Health, will be searched for relevant studies. Two reviewers will then screen studies and review full texts to identify studies for inclusion. Data extraction will be performed, and for included studies, the risk of bias and certainty of the evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation approach. The prognostic factor in this study is visual function, which must have been measured using a standard objective ophthalmic clinical or research instrument. We will use standard criteria from WHO to categorise VI and blindness. All-cause mortality may be assessed by any method one or more years after baseline assessment of vision. Results from included studies will be meta-analysed according to relevant sections of the Meta-analysis Of Observational Studies in Epidemiology checklist. ETHICS AND DISSEMINATION This review will only include published data; therefore, ethics approval will not be sought. The findings of this review and meta-analysis will be published in an open-access, peer-reviewed journal and will be included in the ongoing Lancet Global Health Commission on Global Eye Health.
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Affiliation(s)
- Joshua R Ehrlich
- Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Jacqueline Ramke
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Bonnielin K Swenor
- Ophthalmology, Johns Hopkins University, Baltimore, Maryland, USA
- Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Helen Burn
- Ophthalmology Department, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK
| | - Chan Ning Lee
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - William J Waldock
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Justine H Zhang
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Manchester Royal Eye Hospital, Manchester, UK
| | - Iris Gordon
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Nathan Congdon
- Global Eye Health, Queen's University Belfast, Belfast, UK
- Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Matthew Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Moorfields Eye Hospital, London, UK
| | - Jennifer R Evans
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
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Rono H, Bastawrous A, Macleod D, Bunywera C, Mamboleo R, Wanjala E, Burton M. Smartphone-Guided Algorithms for Use by Community Volunteers to Screen and Refer People With Eye Problems in Trans Nzoia County, Kenya: Development and Validation Study. JMIR Mhealth Uhealth 2020; 8:e16345. [PMID: 32558656 PMCID: PMC7334755 DOI: 10.2196/16345] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/17/2019] [Accepted: 12/15/2019] [Indexed: 01/18/2023] Open
Abstract
Background The provision of eye care services is currently insufficient to meet the requirements of eye care. Many people remain unnecessarily visually impaired or at risk of becoming so because of treatable or preventable eye conditions. A lack of access and awareness of services is, in large part, a key barrier to handle this unmet need. Objective This study aimed to assess whether utilizing novel smartphone-based clinical algorithms can task-shift eye screening to community volunteers (CVs) to accurately identify and refer patients to primary eye care services. In particular, we developed the Peek Community Screening app and assessed its validity in making referral decisions for patients with eye problems. Methods We developed a smartphone-based clinical algorithm (the Peek Community Screening app) using age, distance vision, near vision, and pain as referral criteria. We then compared CVs’ referral decisions using this app with those made by an experienced ophthalmic clinical officer (OCO), which was the reference standard. The same participants were assessed by a trained CV using the app and by an OCO using standard outreach equipment. The outcome was the proportion of all decisions that were correct when compared with that of the OCO. Results The required sensitivity and specificity for the Peek Community Screening app were achieved after seven iterations. In the seventh iteration, the OCO identified referable eye problems in 65.9% (378/574) of the participants. CVs correctly identified 344 of 378 (sensitivity 91.0%; 95% CI 87.7%-93.7%) of the cases and correctly identified 153 of 196 (specificity 78.1%; 95% CI 71.6%-83.6%) cases as not having a referable eye problem. The positive predictive value was 88.9% (95% CI 85.3%-91.8%), and the negative predictive value was 81.8% (95% CI 75.5%-87.1%). Conclusions Development of such an algorithm is feasible; however, it requires considerable effort and resources. CVs can accurately use the Peek Community Screening app to identify and refer people with eye problems. An iterative design process is necessary to ensure validity in the local context.
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Affiliation(s)
- Hillary Rono
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Kitale County and Referral Hospital, Kitale, Kenya
| | - Andrew Bastawrous
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Peek Vision Foundation, London, United Kingdom
| | - David Macleod
- Medical Research Council Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Cosmas Bunywera
- Kitale County and Referral Hospital, Kitale, Kenya.,Peek Vision Foundation, London, United Kingdom
| | | | | | - Matthew Burton
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Moorfields Eye Hospital NHS Trust, London, United Kingdom
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Mndeme FG, Mmbaga BT, Msina M, Mwende J, Vaitha SJ, Kim MJ, Macleod D, Burton MJ, Gilbert CE, Bowman R. Presentation, surgery and 1-year outcomes of childhood cataract surgery in Tanzania. Br J Ophthalmol 2020; 105:334-340. [PMID: 32522793 PMCID: PMC7907562 DOI: 10.1136/bjophthalmol-2020-316042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/30/2020] [Accepted: 04/23/2020] [Indexed: 11/04/2022]
Abstract
Background Recent reports have suggested a significant change in the causes of blindness in children in low-income countries cataract becoming the leading cause. We aimed to investigate the presentations and surgical outcomes in children with cataract operated at different ages in Tanzania. Methods We conducted a prospective study of 228 children aged ≤192 months at three tertiary centres, 177 with bilateral cataracts and prospectively followed them for 1-year postsurgery. We collected demographic, surgical, preoperative and postoperative clinical characteristics using the standard childhood cataract surgical assessment questionnaire. Families were encouraged to return for follow-up by phone with travel reimbursement where necessary. Results Preoperatively, 76% bilateral children were blind in the better eye. 86% of children were followed up at 1 year and 54% bilateral children achieved visual acuity of 0.48 logMAR or better in the better eye and 5% were blind. 33% of unilateral children achieved visual acuity of 0.48 logMAR or better and 17% were blind. Preoperative blindness (adjusted OR (AOR) 14.65; 95% CI 2.21 to 97.20), preoperative nystagmus/strabismus (AOR 9.22; 95% CI 2.66 to 31.97) and aphakia (AOR, 5.32; 95% CI 1.05 to 26.97) predicted poor visual outcome in bilateral cases. 9% of 342 refracted eyes had initial postoperative cylinder of 1.5 D or more, as did a similar proportion (11%) of 315 eyes refracted 1 year after surgery. Acute fibrinous uveitis occurred in 41 (12%) eyes. Conclusion Three-quarters of children were blind preoperatively whereas over half had good vision 1-year postoperatively. Preoperative blindness, nystagmus/strabismus and aphakia predicted poor visual outcome, suggesting that cataract density determines density of amblyopia.
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Affiliation(s)
- Furahini Godfrey Mndeme
- Ophthalmology, Kilimanjaro Christian Medical University Collage, Moshi, Tanzania, United Republic of .,Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Blandina Theophyl Mmbaga
- Paediatrics, Kilimanjaro Clinical Research Institute, Kilimanjaro Christian medical Centre, Moshi, Tanzania, United Republic of
| | - Mchikirwa Msina
- Ophthalmology, Kilimanjaro Christian Medical University Collage, Moshi, Tanzania, United Republic of
| | - Judith Mwende
- Ophthalmology, Muhimbili National Hospital, Dar-Es-Salaam, Dar-Es-Salaam, Tanzania, United Republic of
| | - Sonia J Vaitha
- Ophthalmology, Comprehensive Community Based Rehabilitation in Tanzania, Dar-Es-Salaam, Tanzania, United Republic of
| | - Min J Kim
- Tropical Epidemiology Group, Faculty of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, London, UK
| | - David Macleod
- Tropical Epidemiology Group, Faculty of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, London, UK.,Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Clare E Gilbert
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard Bowman
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.,Ophthalmology, Great Ormond Street Hospital, London, UK
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Spreckley M, Macleod D, González Trampe B, Smith A, Kuper H. Impact of Hearing Aids on Poverty, Quality of Life and Mental Health in Guatemala: Results of a before and after Study. Int J Environ Res Public Health 2020; 17:ijerph17103470. [PMID: 32429252 PMCID: PMC7277678 DOI: 10.3390/ijerph17103470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/28/2020] [Accepted: 05/08/2020] [Indexed: 11/16/2022]
Abstract
There are 466 million people globally with disabling hearing loss, many of whom can benefit from hearing aids. The aim of the study was to assess the impact of providing hearing aids on poverty, mental health, quality of life, and activities, among adults in Guatemala. A nonrandomised before and after study was conducted, with a comparison group to assess for secular trends. Adult cases with bilateral hearing impairment were identified within 150 km of Guatemala City, as well as age- and sex-matched comparison subjects without disabling hearing loss. All participants were interviewed with a semistructured questionnaire, and cases were offered hearing aids. Participants were reinterviewed 6–9 months later. We interviewed 135 cases and 89 comparison subjects at baseline and follow-up. At baseline, cases were poorer than comparison subjects with respect to individual income (p = 0.01), household income (p = 0.02), and per capita expenditure (PCE) (p = 0.003). After provision of hearing aids, median household income improved among cases (p = 0.03). In the comparison group, median individual income (p = 0.01) and PCE (p = 0.03) fell between baseline at follow-up. At follow-up, there were also improvements in productive time use, quality of life, and depressive symptoms among cases, but these were less apparent in the comparison group. In conclusion, this study has demonstrated a positive effect of hearing aids in improving quality of life, economic circumstances and mental health among Guatemalan adults.
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Affiliation(s)
- Mark Spreckley
- Health and Social Care/Allied Health Sciences, London South Bank University, London SE11 0AA, UK;
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
| | | | - Andrew Smith
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
| | - Hannah Kuper
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
- Correspondence: ; Tel.: +44-207-958-8333
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Floyd S, Shanaube K, Yang B, Schaap A, Griffith S, Phiri M, Macleod D, Sloot R, Sabapathy K, Bond V, Bock P, Ayles H, Fidler S, Hayes R. HIV testing and treatment coverage achieved after 4 years across 14 urban and peri-urban communities in Zambia and South Africa: An analysis of findings from the HPTN 071 (PopART) trial. PLoS Med 2020; 17:e1003067. [PMID: 32240156 PMCID: PMC7117659 DOI: 10.1371/journal.pmed.1003067] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/26/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 targets: that 90% of people living with HIV know their HIV status, that 90% of those who know their HIV-positive status are on antiretroviral therapy (ART), and that 90% of those on treatment are virally suppressed. The aim was to reach these targets by 2020. We assessed the feasibility of achieving the first two targets, and the corresponding 81% ART coverage target, as part of the HIV Prevention Trials Network (HPTN) 071 Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART) community-randomized trial. METHODS AND FINDINGS The study population was individuals aged ≥15 years living in 14 urban and peri-urban "PopART intervention" communities in Zambia and South Africa (SA), with a total population of approximately 600,000 and approximately 15% adult HIV prevalence. Community HIV care providers (CHiPs) delivered the PopART intervention during 2014-2017. This was a combination HIV prevention package including universal home-based HIV testing, referral of HIV-positive individuals to government HIV clinic services that offered universal ART (Arm A) or ART according to national guidelines (Arm B), and revisits to HIV-positive individuals to support linkage to HIV care and retention on ART. The intervention was delivered in 3 "rounds," each about 15 months long, during which CHiPs visited all households and aimed to contact all individuals aged ≥15 years at least once. In Arm A in Round 3 (R3), 67% (41,332/61,402) of men and 86% (56,345/65,896) of women in Zambia and 56% (17,813/32,095) of men and 71% (24,461/34,514) of women in SA participated in the intervention, among 193,907 residents aged ≥15 years. Following participation, HIV status was known by 90% of men and women in Zambia and by 78% of men and 85% of women in SA. The median time from CHiP referral of HIV-positive individuals to ART initiation was approximately 3 months. By the end of R3, an estimated 95% of HIV-positive women and 85% of HIV-positive men knew their HIV status, and among these individuals, approximately 90% of women and approximately 85% of men were on ART. ART coverage among all HIV-positive individuals was approximately 85% in women and approximately 75% in men, up from about 45% at the start of the study. ART coverage was lowest among men aged 18 to 34 and women aged 15 to 24 years, and among mobile individuals/in-migrants. Findings from Arm B were similar. The main limitations to our study were that estimates of testing and treatment coverage among men relied on considerable extrapolation because, in each round, approximately one-third of men did not participate in the PopART intervention; that our findings are for a service delivery model that was relatively intensive; and that we did not have comparable data from the 7 "standard-of-care" (Arm C) communities. CONCLUSIONS Our study showed that very high HIV testing and treatment coverage can be achieved through persistent delivery of universal testing, facilitated linkage to HIV care, and universal treatment services. The ART coverage target of 81% was achieved overall, after 4 years of delivery of the PopART intervention, though important gaps remained among men and young people. Our findings are consistent with previously reported findings from southern and east Africa, extending their generalisability to urban settings with high rates of in-migration and mobility and to Zambia and SA. TRIAL REGISTRATION ClinicalTrials.gov NCT01900977.
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Affiliation(s)
- Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kwame Shanaube
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - Blia Yang
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Ab Schaap
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sam Griffith
- FHI 360, HIV Prevention Trials Network, Durham, North Carolina, United States of America
| | - Mwelwa Phiri
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rosa Sloot
- Department of Global Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kalpana Sabapathy
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Virginia Bond
- Department of Global Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Helen Ayles
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- HIV Clinical Trials Unit, Imperial College London, London, United Kingdom
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Last A, Versteeg B, Shafi Abdurahman O, Robinson A, Dumessa G, Abraham Aga M, Shumi Bejiga G, Negussu N, Greenland K, Czerniewska A, Thomson N, Cairncross S, Sarah V, Macleod D, Solomon AW, Logan J, Burton MJ. Detecting extra-ocular Chlamydia trachomatis in a trachoma-endemic community in Ethiopia: Identifying potential routes of transmission. PLoS Negl Trop Dis 2020; 14:e0008120. [PMID: 32130213 PMCID: PMC7075638 DOI: 10.1371/journal.pntd.0008120] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 03/16/2020] [Accepted: 02/06/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Trachoma elimination efforts are hampered by limited understanding of Chlamydia trachomatis (Ct) transmission routes. Here we aimed to detect Ct DNA at non-ocular sites and on eye-seeking flies. METHODS A population-based household survey was conducted in Oromia Region, Ethiopia. Ocular and non-ocular (faces, hands, clothing, water containers and sleeping surfaces) swabs were collected from all individuals. Flies were caught from faces of children. Flies, ocular swabs and non-ocular swabs were tested for Ct by quantitative PCR. RESULTS In total, 1220 individuals in 247 households were assessed. Active trachoma (trachomatous inflammation-follicular) and ocular Ct were detected in 10% and 2% of all-ages, and 21% and 3% of 1-9-year-olds, respectively. Ct was detected in 12% (95% CI:8-15%) of tested non-ocular swabs from ocular-positive households, but in none of the non-ocular swabs from ocular-negative households. Ct was detected on 24% (95% CI:18-32%) of flies from ocular-positive households and 3% (95% CI:1-6%) of flies from ocular-negative households. CONCLUSION Ct DNA was detected on hands, faces and clothing of individuals living in ocular-positive households suggesting that this might be a route of transmission within Ct infected households. In addition, we detected Ct on flies from ocular-positive households and occasionally in ocular-negative households suggesting that flies might be a vector for transmission within and between Ct infected and uninfected households. These potential transmission routes may need to be simultaneously addressed to suppress transmission.
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Affiliation(s)
- Anna Last
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bart Versteeg
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Oumer Shafi Abdurahman
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- The Fred Hollows Foundation, Ethiopia
| | - Ailie Robinson
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | | | - Katie Greenland
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alexandra Czerniewska
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nicholas Thomson
- Department of Pathogen Molecular Biology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Parasites and microbes, Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, United Kingdom
| | - Sandy Cairncross
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anthony W. Solomon
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - James Logan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Matthew J. Burton
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Robinson A, Bristow J, Holl MV, Makalo P, Alemayehu W, Bailey RL, Macleod D, Birkett MA, Caulfield JC, Sarah V, Pickett JA, Dewhirst S, Chen-Hussey V, Woodcock CM, D’Alessandro U, Last A, Burton MJ, Lindsay SW, Logan JG. Responses of the putative trachoma vector, Musca sorbens, to volatile semiochemicals from human faeces. PLoS Negl Trop Dis 2020; 14:e0007719. [PMID: 32126087 PMCID: PMC7069642 DOI: 10.1371/journal.pntd.0007719] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 03/13/2020] [Accepted: 01/13/2020] [Indexed: 12/12/2022] Open
Abstract
The putative vector of trachoma, Musca sorbens, prefers to lay its eggs on human faeces on the ground. This study sought to determine whether M. sorbens females were attracted to volatile odours from human faeces in preference to odours from the faeces of other animals, and to determine whether specific volatile semiochemicals mediate selection of the faeces. Traps baited with the faeces of humans and local domestic animals were used to catch flies at two trachoma-endemic locations in The Gambia and one in Ethiopia. At all locations, traps baited with faeces caught more female M. sorbens than control traps baited with soil, and human faeces was the most successful bait compared with soil (mean rate ratios 44.40, 61.40, 10.50 [P<0.001]; 8.17 for child faeces [P = 0.004]). Odours from human faeces were sampled by air entrainment, then extracts of the volatiles were tested by coupled gas chromatography-electroantennography with laboratory-reared female M. sorbens. Twelve compounds were electrophysiologically active and tentatively identified by coupled mass spectrometry-gas chromatography, these included cresol, indole, 2-methylpropanoic acid, butanoic acid, pentanoic acid and hexanoic acid. It is possible that some of these volatiles govern the strong attraction of M. sorbens flies to human faeces. If so, a synthetic blend of these chemicals, at the correct ratios, may prove to be a highly attractive lure. This could be used in odour-baited traps for monitoring or control of this species in trachoma-endemic regions.
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Affiliation(s)
- Ailie Robinson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Julie Bristow
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
- Biological Chemistry and Crop Protection, Rothamsted Research, Harpenden, Hertfordshire, United Kingdom
| | - Matthew V. Holl
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Pateh Makalo
- Medical Research Council Unit, The Gambia, The Gambia
| | | | - Robin L. Bailey
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael A. Birkett
- Biological Chemistry and Crop Protection, Rothamsted Research, Harpenden, Hertfordshire, United Kingdom
| | - John C. Caulfield
- Biological Chemistry and Crop Protection, Rothamsted Research, Harpenden, Hertfordshire, United Kingdom
| | - Virginia Sarah
- Global Partnerships Executive, The Fred Hollows Foundation, Crawford Mews, London, United Kingdom
| | - John A. Pickett
- Biological Chemistry and Crop Protection, Rothamsted Research, Harpenden, Hertfordshire, United Kingdom
| | - Sarah Dewhirst
- ARCTEC, Chariot Innovations Ltd, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Vanessa Chen-Hussey
- ARCTEC, Chariot Innovations Ltd, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christine M. Woodcock
- Biological Chemistry and Crop Protection, Rothamsted Research, Harpenden, Hertfordshire, United Kingdom
| | | | - Anna Last
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew J. Burton
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Steve W. Lindsay
- Department of Biosciences, Durham University, Durham, County Durham, United Kingdom
| | - James G. Logan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
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Philippin H, Knoll KM, Macleod D. COVID-19 numbers and models: misleading us, or leading us out of misery? Community Eye Health 2020; 33:43-45. [PMID: 33304055 PMCID: PMC7677793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Heiko Philippin
- Clinical Research Fellow: International Centre for Eye Health, London School of Hygiene & Tropical Medicine, UK, Global Advisor for Inclusive Eye Health/Research & Training: CBM, Bensheim, Germany, and Glaucoma Specialist: Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Karin M Knoll
- Consultant Ophthalmologist: Kilimanjaro Christian Medical Centre, Moshi, Tanzania and CBM, Bensheim, Germany
| | - David Macleod
- Assistant Professor: MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, UK
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Arunga S, Wiafe G, Habtamu E, Onyango J, Gichuhi S, Leck A, Macleod D, Hu V, Burton M. The impact of microbial keratitis on quality of life in Uganda. BMJ Open Ophthalmol 2019; 4:e000351. [PMID: 31909191 PMCID: PMC6936408 DOI: 10.1136/bmjophth-2019-000351] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/04/2019] [Accepted: 12/01/2019] [Indexed: 11/16/2022] Open
Abstract
Background Microbial keratitis (MK) is a frequent cause of sight loss in sub-Saharan Africa. However, no studies have formally measured its impact on quality of life (QoL) in this context. Methods As part of a nested case–control design for risk factors of MK, we recruited patients presenting with MK at two eye units in Southern Uganda between December 2016 and March 2018 and unaffected individuals, individually matched for sex, age and location. QoL was measured using WHO Health-Related and Vision-Related QoL tools (at presentation and 3 months after start of treatment in cases). Mean QoL scores for both groups were compared. Factors associated with QoL among the cases were analysed in a linear regression model. Results 215 case-controls pairs were enrolled. The presentation QoL scores for the cases ranged from 20 to 65 points. The lowest QoL was visual symptom domain; mean 20.7 (95% CI 18.8 to 22.7) and the highest was psychosocial domain; mean 65.6 (95% CI 62.5 to 68.8). At 3 months, QoL scores for the patients ranged from 80 to 90 points while scores for the controls ranged from 90 to 100. The mean QoL scores of the cases were lower than controls across all domains. Determinants of QoL among the cases at 3 months included visual acuity at 3 months and history of eye loss. Conclusion MK severely reduces QoL in the acute phase. With treatment and healing, QoL subsequently improves. Despite this improvement, QoL of someone affected by MK (even with normal vision) remains lower than unaffected controls.
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Affiliation(s)
- Simon Arunga
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK, UK.,Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Geoffrey Wiafe
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Esmael Habtamu
- London School of Hygiene and Tropical Medicine International Centre for Eye Health, London, UK.,Carter Center, Addis Ababa, Ethiopia
| | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - David Macleod
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Victor Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Burton
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
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Arunga S, Kintoki GM, Mwesigye J, Ayebazibwe B, Onyango J, Bazira J, Newton R, Gichuhi S, Leck A, Macleod D, Hu VH, Burton MJ. Epidemiology of Microbial Keratitis in Uganda: A Cohort Study. Ophthalmic Epidemiol 2019; 27:121-131. [PMID: 31830848 PMCID: PMC7446037 DOI: 10.1080/09286586.2019.1700533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To describe the epidemiology of Microbial Keratitis (MK) in Uganda. Methods We prospectively recruited patients presenting with MK at two main eye units in
Southern Uganda between December 2016 and March 2018. We collected information on
clinical history and presentation, microbiology and 3-month outcomes. Poor vision was
defined as vision < 6/60). Results 313 individuals were enrolled. Median age was 47 years (range 18–96) and 174 (56%) were
male. Median presentation time was 17 days from onset (IQR 8–32). Trauma was reported by
29% and use of Traditional Eye Medicine by 60%. Majority presented with severe
infections (median infiltrate size 5.2 mm); 47% were blind in the affected eye (vision
< 3/60). Microbiology was available from 270 cases: 62% were fungal, 7% mixed
(bacterial and fungal), 7% bacterial and 24% no organism detected. At 3 months, 30% of
the participants were blind in the affected eye, while 9% had lost their eye from the
infection. Delayed presentation (overall p = .007) and
prior use of Traditional Eye Medicine (aOR 1.58 [95% CI 1.04–2.42], p = .033) were responsible for poor presentation. Predictors of poor vision
at 3 months were: baseline vision (aOR 2.98 [95%CI 2.12–4.19], p < .0001), infiltrate size (aOR 1.19 [95%CI 1.03–1.36], p < .020) and perforation at presentation (aOR 9.93 [95% CI
3.70–26.6], p < .0001). Conclusion The most important outcome predictor was the state of the eye at presentation,
facilitated by prior use of Traditional Eye Medicine and delayed presentation. In order
to improve outcomes, we need effective early interventions.
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Affiliation(s)
- Simon Arunga
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.,Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Guyguy M Kintoki
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - James Mwesigye
- Department of Microbiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joel Bazira
- Department of Microbiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rob Newton
- Department of epidemiology, Uganda Virus Research Institute, Entebbe, Uganda
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - David Macleod
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Victor H Hu
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
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Habtamu E, Wondie T, Tadesse Z, Atinafu B, Gashaw B, Gebeyehu A, Kelly Callahan E, Macleod D, Burton MJ. Posterior lamellar versus bilamellar tarsal rotation surgery for trachomatous trichiasis: Long-term outcomes from a randomised controlled trial. EClinicalMedicine 2019; 17:100202. [PMID: 31891136 PMCID: PMC6933225 DOI: 10.1016/j.eclinm.2019.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/14/2019] [Accepted: 10/21/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We re-examined the participants of a clinical trial four years after enrolment to identify which of the two most commonly used eyelid surgery procedures to treat the blinding stage of trachoma (trachomatous trichiasis, TT), the posterior Lamellar Tarsal Rotation (PLTR) and Billamelar Tarsal Rotation (BLTR), gives better results in the long-term. METHODS A randomised, controlled, single masked clinical trial was done in Ethiopia. At baseline, adults (aged >18 years with upper lid unoperated TT were recruited from a community-based screening. Participants were randomly assigned (1:1), to either BLTR or PLTR surgery, stratified by surgeon. At 4 years an independent assessor masked to allocation examined the trial participants' eyes using the same procedures as for the baseline and earlier follow-ups. The primary outcome was the proportion of individuals who had recurrence (postoperative TT, PTT) at the 4-year examination, or a history of repeat surgery in the 4-year period. The intervention effect was estimated by logistic regression, controlled for surgeon as a fixed effect in the model. The trial is registered with the Pan African Clinical Trials Registry (number PACTR201401000743135). FINDINGS 1000 participants with TT were enrolled, randomly assigned, and treated (501 in the BLTR group and 499 in the PLTR group) between Feb 13, 2014, and May 31, 2014. At year 4, 943 (94.3%) participants were re-examined (471, PLTR; 472, BLTR) and included in the primary outcome analysis. PTT had developed in 169/943 (17•9%) study eyes, among which 129 (76•3%) had minor trichiasis (≤5 lashes touching the eye). PTT was significantly more frequent at 4-year in the BLTR arm (105/472 [22•2%]) than the PLTR arm (64/471 [13•6%]), adjusted OR 1•82 (95% CI, 1•29-2•56); p = 0•0006, with 8•6% (95%CI 3•8-13•5) risk difference. INTERPRETATION The PLTR surgical procedure had superior long-term outcomes to the BLTR with significantly lower risk of PTT supporting the current WHO guideline that the PLTR should be the procedure of choice for training new surgeons in the programmatic management of TT.
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Affiliation(s)
- Esmael Habtamu
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- The Carter Center, Addis Ababa, Ethiopia
| | | | | | | | | | | | | | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J. Burton
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Arunga S, Kintoki GM, Gichuhi S, Onyango J, Ayebazibwe B, Newton R, Leck A, Macleod D, Hu VH, Burton MJ. Risk Factors of Microbial Keratitis in Uganda: A Case Control Study. Ophthalmic Epidemiol 2019; 27:98-104. [PMID: 31640454 PMCID: PMC7446035 DOI: 10.1080/09286586.2019.1682619] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: Microbial keratitis (MK), is a frequent cause of sight loss worldwide, particularly in low and middle-income countries. This study aimed to investigate the risk factors of MK in Uganda.Methods: Using a nested case control, we recruited healthy community controls for patients presenting with MK at the two main eye units in Southern Uganda between December 2016 and March 2018. Controls were individually matched for age, gender and village of the cases on a 1:1 ratio. We collected information on demographics, occupation, HIV and Diabetes Mellitus status. In STATA version 14.1, multivariable conditional logistic regression was used to generate odds ratios for risk factors of MK and a likelihood ratio test used to assess statistical significance of associations.Results: Two hundred and fifteen case-control pairs were enrolled. The HIV positive patients among the cases was 9% versus 1% among the controls, p = .0003. Diabetes 7% among the cases versus 1.4% among the controls, p = .012. Eye trauma was 29% versus 0% among the cases and controls. In the multivariable model adjusted for age, sex and village, HIV (OR 83.5, 95%CI 2.01-3456, p = .020), Diabetes (OR 9.38, 95% CI 1.48-59.3, p = .017) and a farming occupation (OR 2.60, 95%CI 1.21-5.57, p = .014) were associated with MK. Compared to a low socio-economic status, a middle status was less likely to be associated with MK (OR 0.29, 95%CI 0.09-0.89, p < .0001).Conclusion: MK was associated with HIV, Diabetes, being poor and farming as the main occupation. More studies are needed to explore how these factors predispose to MK.
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Affiliation(s)
- Simon Arunga
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.,Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Guyguy M Kintoki
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Rob Newton
- Department of Epidemiology, Uganda Virus Research Institute, Entebbe, Uganda
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - David Macleod
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Victor H Hu
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
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Arunga S, Asiimwe A, Apio Olet E, Kagoro-Rugunda G, Ayebazibwe B, Onyango J, Newton R, Leck A, Macleod D, Hu VH, Seeley J, Burton MJ. Traditional eye medicine use in microbial keratitis in Uganda: a mixed methods study. Wellcome Open Res 2019; 4:89. [PMID: 31633056 PMCID: PMC6784788 DOI: 10.12688/wellcomeopenres.15259.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Traditional eye medicine (TEM) is frequently used to treat microbial keratitis (MK) in many parts of Africa. Few reports have suggested that this is associated with a worse outcome. We undertook this large prospective study to determine how TEM use impacts presentation and outcome of MK and to explore reasons why people use TEM for treatment in Uganda. Methods: In a mixed method prospective cohort study, we enrolled patients presenting with MK at the two main eye units in Southern Uganda between December 2016 and March 2018 and collected information on history, TEM use, microbiology and 3-month outcomes. We conducted qualitative interviews with patients, carers traditional healers on reasons why people use TEM. Outcome measures included presenting vision and at 3-months, comparing TEM Users versus Non-Users. A thematic coding framework was deployed to explore reasons for use of TEM. Results: Out of 313 participants enrolled, 188 reported TEM use. TEM Users had a delayed presentation; median presenting time 18 days versus 14 days, p= 0.005; had larger ulcers 5.6 mm versus 4.3 mm p=0.0005; a worse presenting visual acuity median logarithm of the minimum angle of resolution (Log MAR) 1.5 versus 0.6, p=0.005; and, a worse visual acuity at 3 months median Log MAR 0.6 versus 0.2, p=0.010. In a multivariable logistic regression model, distance from the eye hospital and delayed presentation were associated with TEM use. Reasons for TEM use included lack of confidence in conventional medicine, health system breakdown, poverty, fear of the eye hospital, cultural belief in TEM, influence from traditional healers, personal circumstances and ignorance. Conclusion: TEM users had poorer clinical presentation and outcomes. Capacity building of the primary health centres to improve access to eye care and community behavioural change initiatives against TEM use should be encouraged.
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Affiliation(s)
- Simon Arunga
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Allen Asiimwe
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
| | - Eunice Apio Olet
- Department of Biology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Grace Kagoro-Rugunda
- Department of Biology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Robert Newton
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
- University of York, UK, York, YO10 5DD, UK
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - David Macleod
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Victor H. Hu
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Janet Seeley
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
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