Greater Disease Severity and Worse Clinical Outcomes in Patients Hospitalised with COVID-19 in Africa

Background

COVID-19 cardiovascular research from Africa is limited. This study describes cardiovascular risk factors, manifestations, and outcomes of patients hospitalised with COVID-19 in the African region, with an overarching goal to investigate whether important differences exist between African and other populations, which may inform health policies.

Methods

A multinational prospective cohort study was conducted on adults hospitalised with confirmed COVID-19, consecutively admitted to 40 hospitals across 23 countries, 6 of which were African countries. Of the 5,313 participants enrolled globally, 948 were from African sites (n = 9). Data on demographics, pre-existing conditions, clinical outcomes in hospital (major adverse cardiovascular events (MACE), renal failure, neurological events, pulmonary outcomes, and death), 30-day vitality status and re-hospitalization were assessed, comparing African to non-African participants.

Results

Access to specialist care at African sites was significantly lower than the global average (71% vs. 95%), as were ICU admissions (19.4% vs. 34.0%) and COVID-19 vaccination rates (0.6% vs. 7.4%). The African cohort was slightly younger than the non-African cohort (55.0 vs. 57.5 years), with higher rates of hypertension (48.8% vs. 46.9%), HIV (5.9% vs. 0.3%), and Tuberculosis (3.6% vs. 0.3%). In African sites, a higher proportion of patients suffered cardiac arrest (7.5% vs. 5.1%) and acute kidney injury (12.7% vs. 7.2%), with acute kidney injury (AKI) appearing to be one of the strongest predictors of MACE and death in African populations compared to other populations. The overall mortality rate was significantly higher among African participants (18.2% vs. 14.2%).

Conclusions

Overall, hospitalised African patients with COVID-19 had a higher mortality despite a lower mean age, contradicting literature that had previously reported a lower mortality attributed to COVID-19 in Africa. African sites had lower COVID-19 vaccination rates and higher AKI rates, which were positively associated with increased mortality. In conclusion, African patients were hospitalized with more severe COVID-19 cases and had poorer outcomes.

Heart failure, the global pandemic: A call to action consensus statement from the global presidential conclave at the platinum jubilee conference of cardiological society of India 2023

Heart failure (HF) is emerging as a major public health problem both in high- and low - income countries. The mortality and morbidity due to HF is substantially higher in low-middle income countries (LMICs). Accessibility, availability and affordability issues affect the guideline directed therapy implementation in HF care in those countries. This call to action urges all those concerned to initiate preventive strategies as early as possible, so that we can reduce HF-related morbidity and mortality. The most important step is to have better prevention and treatment strategies for diseases such as hypertension, ischemic heart disease (IHD), type-2 diabetes, and rheumatic heart disease (RHD) which predispose to the development of HF. Setting up dedicated HF-clinics manned by HF Nurses, can help in streamlining HF care. Subsidized in-patient care, financial assistance for device therapy, use of generic medicines (including polypill strategy) will be helpful, along with the use of digital technologies.

Remote Ischaemic Conditioning in STEMI Patients in Sub-Saharan AFRICA: Rationale and Study Design for the RIC-AFRICA Trial

PURPOSE

Despite evidence of myocardial infarct size reduction in animal studies, remote ischaemic conditioning (RIC) failed to improve clinical outcomes in the large CONDI-2/ERIC-PPCI trial. Potential reasons include that the predominantly low-risk study participants all received timely optimal reperfusion therapy by primary percutaneous coronary intervention (PPCI). Whether RIC can improve clinical outcomes in higher-risk STEMI patients in environments with poor access to early reperfusion or PPCI will be investigated in the RIC-AFRICA trial.

METHODS

The RIC-AFRICA study is a sub-Saharan African multi-centre, randomized, double-blind, sham-controlled clinical trial designed to test the impact of RIC on the composite endpoint of 30-day mortality and heart failure in 1200 adult STEMI patients without access to PPCI. Randomized participants will be stratified by whether or not they receive thrombolytic therapy within 12 h or arrive outside the thrombolytic window (12-24 h). Participants will receive either RIC (four 5-min cycles of inflation [20 mmHg above systolic blood pressure] and deflation of an automated blood pressure cuff placed on the upper arm) or sham control (similar protocol but with low-pressure inflation of 20 mmHg and deflation) within 1 h of thrombolysis and applied daily for the next 2 days. STEMI patients arriving greater than 24 h after chest pain but within 72 h will be recruited to participate in a concurrently running independent observational arm.

CONCLUSION

The RIC-AFRICA trial will determine whether RIC can reduce rates of death and heart failure in higher-risk sub-optimally reperfused STEMI patients, thereby providing a low-cost, non-invasive therapy for improving health outcomes.

Effect of 3, 2-Drug Combinations of Antihypertensive Therapies on Blood Pressure Variability in Black African Patients: Secondary Analyses of the CREOLE Trial

Background:

The effect of 3 commonly recommended combinations of anti-hypertensive agents—amlodipine plus hydrochlorothiazide (calcium channel blocker [CCB]+thiazide), amlodipine plus perindopril (CCB+ACE [angiotensin-converting enzyme]-inhibitor), and perindopril plus hydrochlorothiazide (ACE-inhibitor+thiazide) on blood pressure variability (V) are unknown.

Methods:

We calculated the blood pressure variability (BPV) in 405 patients (130, 146, and 129 randomized to ACE-inhibitor+thiazide, CCB+thiazide, and CCB+ACE-inhibitor, respectively) who underwent ambulatory blood pressure monitoring after 6 months of treatment in the Comparisons of Three Combinations Therapies in Lowering Blood Pressure in Black Africans trial (CREOLE) of Black African patients. BPV was calculated using the SD of 30-minute interval values for 24-hour ambulatory BPs and for confirmation using the coefficient of variation. Linear mixed model regression was used to calculate mean differences in BPV between treatment arms. Within-clinic BPV was also calculated from the mean SD and coefficient of variation of 3 readings at clinic visits.

Results:

Baseline distributions of age, sex, and blood pressure parameters were similar across treatment groups. Participants were predominately male (62.2%) with mean age 50.4 years. Those taking CCB+thiazide had significantly reduced ambulatory systolic and diastolic BPV compared with those taking ACE-inhibitor+thiazide. The CCB+thiazide and CCB+ACE-inhibitor groups showed similar BPV. Similar patterns of BPV were apparent among groups using within-clinic blood pressures and when assessed by coefficient of variation.

Conclusions:

Compared with CCB-containing combinations, ACE-inhibitor plus thiazide was associated with higher levels, generally significant, of ambulatory and within-clinic systolic and diastolic BPV. These results supplement the differential ambulatory blood pressure–lowering effects of these therapies in the CREOLE trial.

A Differential Response to Antihypertensive Therapy in African Men and Women: Insights From the CREOLE Trial

BACKGROUND

We sought to address the paucity of data to support the evidence-based management of hypertension to achieve optimal blood pressure (BP) control on a sex-specific basis in Africa.

METHODS

We undertook a post hoc analysis of the multicenter, randomized CREOLE (Comparison of Three Combination Therapies in Lowering Blood Pressure in Black Africans) Trial to test the hypothesis that there would be clinically important differences in office BP control between African men and women. We compared the BP levels of 397 and 238 hypertensive women (63%, 50.9 ± 10.5 years) and men (51.2 ± 11.3 years) from 10 sites across sub-Saharan Africa who completed baseline and 6-month profiling according to their randomly allocated antihypertensive treatment.

RESULTS

Overall, 442/635 (69.6%) participants achieved an office BP target of <140/90 mm Hg at 6 months; comprising more women (286/72.0%) than men (156/65.5%) (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 1.07-2.39; P = 0.023). Women randomized to amlodipine-hydrochlorothiazide (HCTZ) (adjusted OR 3.03, 95% CI 1.71-5.35; P < 0.001) or amlodipine-perindopril (adjusted OR 2.62, 95% CI 1.49-4.58; P = 0.01) were more likely to achieve this target compared with perindopril-HCTZ. Among men, there were no equivalent treatment differences-amlodipine-HCTZ (OR 1.54, 95% CI 0.76-3.12; P = 0.23) or amlodipine-perindopril (OR 1.32, 95% CI 0.65-2.67; P = 0.44) vs. perindopril-HCTZ. Among the 613 participants (97%) with 24-hour ambulatory BP monitoring, women had significantly lower systolic (124.1 ± 18.1 vs. 127.3 ± 16.9; P = 0.028) and diastolic (72.7 ± 10.4 vs. 75.1 ± 10.5; P = 0.007) BP levels at 6 months compared with men.

CONCLUSIONS

These data suggest clinically important differences in the therapeutic response to antihypertensive combination therapy among African women compared with African men.

The joint 15th Pan-African Society of Cardiology and Kenya Cardiac Society congress proceedings, 2021

The 15th biennial Pan-African Society of Cardiology (PASCAR) congress held in Mombasa, Kenya, in November 2021, convened in its legacy of being the largest Pan-African conference on cardiovascular diseases (CVDs). The congress brough together members of cardiovascular societies from across the continent in the shared mission of advancing cardiovascular health in Africa. In partnership with the Kenyan Cardiac Society (KCS), the specific aims of the PASCAR conference were to (1) advance knowledge on CVDs in the region; (2) share local data, clinical cases, challenges and solutions and reinforce collaborative capacity initiatives in research and workforce training; (3) engage with policy makers to address health-system issues affecting access to CVD care in Africa; and (4) bring together local and international thought leaders in cardiovascular medicine to strengthen the partnerships between PASCAR, KCS, other African cardiac societies and key global stakeholders. Due to the COVID-19 pandemic, this congress demonstrated great success in providing both an in-person and a virtual platform of attendance, therefore making this an inaugural hybrid PASCAR congress, with inclusive and widespread participation from across the globe. We highlight the key areas of focus, various educational programmes and innovative initiatives that shaped the 15th PASCAR congress, including expert consensus on the future directions for advancing CVD care in Africa.

A case for implementation of adult pneumococcal vaccine program in Africa: review and expert opinion

Vaccines are considered as a therapeutic area for children; the scientific community focuses mainly on managing chronic disease when it comes to adults. There currently is an increase in the burden of vaccine preventable illnesses in adults. Adult vaccination has been shown to dramatically increase the health and quality of life of older populations. Therefore, adult vaccinations need to be approached as a public health issue, similar to smoking cessation programs, for example. According to the Kenya Non-Communicable Diseases and injuries poverty commission report, 2018. Kenya has a high percentage of disability adjusted life years (DALYs) from communicable diseases at 63%, while non-communicable diseases (NCDs) contribute 30% of the DALYs. Specific to pneumococcal pneumonia (PP) in adults, the Global burden of disease (GBD) study in 2016 found that 2,377,697 people of all ages died from lower respiratory tract infections (LRTI) in 2016. Of these, more people died from Streptococcus pneumonia(SP) than from all other studied respiratory pathogens combined. While the incidence of LRTIs in children under five years old was reducing, partly as a result of well-established vaccination programs in children, the incidence, morbidity and mortality of PP was increasing in older populations. The expert recommendations included the following; i) all individuals 65 years of age and above, and individuals with a predisposing comorbidity regardless of age, should receive the pneumococcal vaccine; ii) several systemic modules can be emulated from the successful childhood vaccines programs onto an adult vaccine program; iii) formulation of an effective vaccine program will require collaboration from the public, the government, healthcare providers, and the media, to create awareness; iv) stakeholders who need to be involved in vaccine policy development and implementation include medical professional associations, nurses, pharmacists, clinical officers, payers (private and public insurances), government, medical learning institutions and faith-based medical organizations.

High prevalence of non-dipping patterns among black Africans with uncontrolled hypertension: a secondary analysis of the CREOLE trial

Background

Dipping of blood pressure (BP) at night is a normal physiological phenomenon. However, a non-dipping pattern is associated with hypertension mediated organ damage, secondary forms of hypertension and poorer long-term outcome. Identifying a non-dipping pattern may be useful in assessing risk, aiding the decision to investigate for secondary causes, initiating treatment, assisting decisions on choice and timing of anti-hypertensive therapy, and intensifying salt restriction.

Objectives

To estimate the prevalence and factors associated with non-dipping pattern and determine the effect of three 6-months anti-hypertensive regimens on the dipping pattern among Black African hypertensive patients.

Methods

This was a secondary analysis of the CREOLE Study which was a randomized, single blind, three-group trial conducted in 10 sites in 6 Sub-Saharan African countries. The participants were 721 Black African patients, aged between 30 and 79 years, with uncontrolled hypertension and a baseline 24-hour ambulatory blood pressure monitoring (ABPM). Dipping was calculated from the average day and average night systolic blood pressure measures.

Results

The prevalence of non-dipping pattern was 78% (564 of 721). Factors that were independently associated with non-dipping were: serum sodium &gt;140mmol/l (OR=1.72, 95% CI: 1.17–2.51, p-value 0.005), a higher office systolic BP (OR=1.03, 95% CI: 1.01–1.05, p-value 0.003) and a lower office diastolic BP (OR=0.97, 95% CI: 0.95–0.99, p-value 0.03). Treatment allocation did not change dipping status at 6 months (McNemar's χ2 0.71, p-value 0.40).

Conclusion

There was a high prevalence of non-dipping among Black Africans with uncontrolled hypertension. ABPM should be considered more routinely in Black Africans with uncontrolled hypertension, if resources permit, to help personalise therapy. Further research is needed to understand the mechanisms and causes of non-dipping pattern and if targeting night-time BP improves clinical outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Fogarty International Center and the National Institutes of Health of the United States of America Figure 1

World Heart Federation Roadmap for Hypertension - A 2021 Update

The World Heart Federation (WHF) Roadmap series covers a large range of cardiovascular conditions. These Roadmaps identify potential roadblocks and their solutions to improve the prevention, detection and management of cardiovascular diseases and provide a generic global framework available for local adaptation. A first Roadmap on raised blood pressure was published in 2015. Since then, advances in hypertension have included the publication of new clinical guidelines (AHA/ACC; ESC; ESH/ISH); the launch of the WHO Global HEARTS Initiative in 2016 and the associated Resolve to Save Lives (RTSL) initiative in 2017; the inclusion of single-pill combinations on the WHO Essential Medicines' list as well as various advances in technology, in particular telemedicine and mobile health. Given the substantial benefit accrued from effective interventions in the management of hypertension and their potential for scalability in low and middle-income countries (LMICs), the WHF has now revisited and updated the 'Roadmap for raised BP' as 'Roadmap for hypertension' by incorporating new developments in science and policy. Even though cost-effective lifestyle and medical interventions to prevent and manage hypertension exist, uptake is still low, particularly in resource-poor areas. This Roadmap examined the roadblocks pertaining to both the demand side (demographic and socio-economic factors, knowledge and beliefs, social relations, norms, and traditions) and the supply side (health systems resources and processes) along the patient pathway to propose a range of possible solutions to overcoming them. Those include the development of population-wide prevention and control programmes; the implementation of opportunistic screening and of out-of-office blood pressure measurements; the strengthening of primary care and a greater focus on task sharing and team-based care; the delivery of people-centred care and stronger patient and carer education; and the facilitation of adherence to treatment. All of the above are dependent upon the availability and effective distribution of good quality, evidence-based, inexpensive BP-lowering agents.

High prevalence of non-dipping patterns among Black Africans with uncontrolled hypertension: a secondary analysis of the CREOLE trial

BACKGROUND

Dipping of blood pressure (BP) at night is a normal physiological phenomenon. However, a non-dipping pattern is associated with hypertension mediated organ damage, secondary forms of hypertension and poorer long-term outcome. Identifying a non-dipping pattern may be useful in assessing risk, aiding the decision to investigate for secondary causes, initiating treatment, assisting decisions on choice and timing of antihypertensive therapy, and intensifying salt restriction.

OBJECTIVES

To estimate the prevalence and factors associated with non-dipping pattern and determine the effect of 6 months of three antihypertensive regimens on the dipping pattern among Black African hypertensive patients.

METHODS

This was a secondary analysis of the CREOLE Study which was a randomized, single blind, three-group trial conducted in 10 sites in 6 Sub-Saharan African countries. The participants were 721 Black African patients, aged between 30 and 79 years, with uncontrolled hypertension and a baseline 24-h ambulatory blood pressure monitoring (ABPM). Dipping was calculated from the average day and average night systolic blood pressure measures.

RESULTS

The prevalence of non-dipping pattern was 78% (564 of 721). Factors that were independently associated with non-dipping were: serum sodium > 140 mmol/l (OR = 1.72, 95% CI 1.17-2.51, p-value 0.005), a higher office systolic BP (OR = 1.03, 95% CI 1.01-1.05, p-value 0.003) and a lower office diastolic BP (OR = 0.97, 95% CI 0.95-0.99, p-value 0.03). Treatment allocation did not change dipping status at 6 months (McNemar's Chi2 0.71, p-value 0.40).

CONCLUSION

There was a high prevalence of non-dipping among Black Africans with uncontrolled hypertension. ABPM should be considered more routinely in Black Africans with uncontrolled hypertension, if resources permit, to help personalise therapy. Further research is needed to understand the mechanisms and causes of non-dipping pattern and if targeting night-time BP improves clinical outcomes. Trial registration ClinicalTrials.gov (NCT02742467).

Cost-effectiveness of risk stratified medication management for reducing premature cardiovascular mortality in Kenya

Background

Cardiovascular disease (CVD) is a major contributor to the burden from non-communicable diseases in Sub-Saharan Africa and hypertension is the leading risk factor for CVD. The objective of this modeling study is to assess the cost-effectiveness of a risk stratified approach to medication management in Kenya in order to achieve adequate blood pressure control to reduce CVD events.

Methods

We developed a microsimulation model to evaluate CVD risk over the lifetime of a cohort of individuals. Risk groups were assigned utilizing modified Framingham study distributions based on individual level risk factors from the Kenya STEPwise survey which collected details on blood pressure, blood glucose, tobacco and alcohol use and cholesterol levels. We stratified individuals into 4 risk groups: very low, low, moderate and high risk. Mortality could occur due to acute CVD events, subsequent future events (for individual who survive the initial event) and other causes. We present cost and DALYs gained due to medication management for men and women 25 to 69 years.

Results

Treating high risk individuals only was generally more cost-effective that treating high and moderate risk individuals. At the anticipated base levels of effectiveness, medication management was only cost-effective under the low cost scenario. The incremental cost per DALY gained with low cost ranged from $1,505 to $3,608, which is well under $4,785 (3 times GPD per capita) threshold for Kenya. Under the low cost scenario, even lower levels of effectiveness of medication management are likely to be cost-effective for high-risk men and women.

Conclusions

In Kenya, our results indicate that the risk stratified approach to treating hypertension may be cost-effective especially for men and women at a high risk for CVD events, but these results are highly sensitive to the cost of medications. Medication management would require significant financial investment and therefore other interventions, including lifestyle changes, should be evaluated especially for those with elevated blood pressure and overall 10-year risk that is less than 20%.

Comparison of Dual Therapies for Lowering Blood Pressure in Black Africans

BACKGROUND

The prevalence of hypertension among black African patients is high, and these patients usually need two or more medications for blood-pressure control. However, the most effective two-drug combination that is currently available for blood-pressure control in these patients has not been established.

METHODS

In this randomized, single-blind, three-group trial conducted in six countries in sub-Saharan Africa, we randomly assigned 728 black patients with uncontrolled hypertension (≥140/90 mm Hg while the patient was not being treated or was taking only one antihypertensive drug) to receive a daily regimen of 5 mg of amlodipine plus 12.5 mg of hydrochlorothiazide, 5 mg of amlodipine plus 4 mg of perindopril, or 4 mg of perindopril plus 12.5 mg of hydrochlorothiazide for 2 months. Doses were then doubled (10 and 25 mg, 10 and 8 mg, and 8 and 25 mg, respectively) for an additional 4 months. The primary end point was the change in the 24-hour ambulatory systolic blood pressure between baseline and 6 months.

RESULTS

The mean age of the patients was 51 years, and 63% were women. Among the 621 patients who underwent 24-hour blood-pressure monitoring at baseline and at 6 months, those receiving amlodipine plus hydrochlorothiazide and those receiving amlodipine plus perindopril had a lower 24-hour ambulatory systolic blood pressure than those receiving perindopril plus hydrochlorothiazide (between-group difference in the change from baseline, -3.14 mm Hg; 95% confidence interval [CI], -5.90 to -0.38; P = 0.03; and -3.00 mm Hg; 95% CI, -5.8 to -0.20; P = 0.04, respectively). The difference between the group receiving amlodipine plus hydrochlorothiazide and the group receiving amlodipine plus perindopril was -0.14 mm Hg (95% CI, -2.90 to 2.61; P=0.92). Similar differential effects on office and ambulatory diastolic blood pressures, along with blood-pressure control and response rates, were apparent among the three groups.

CONCLUSIONS

These findings suggest that in black patients in sub-Saharan Africa, amlodipine plus either hydrochlorothiazide or perindopril was more effective than perindopril plus hydrochlorothiazide at lowering blood pressure at 6 months. (Funded by GlaxoSmithKline Africa Noncommunicable Disease Open Lab; CREOLE ClinicalTrials.gov number, NCT02742467.).

Supporting the Management of Patients with Heart Failure within Asia-Pacific, Middle East, and African Countries: A Toolbox for Healthcare Providers

OBJECTIVES

The management of heart failure (HF) is most effective when established treatment guidelines and recommendations are followed. We aimed to develop a "Toolbox" of resources to facilitate the care of patients with acute HF and chronic HF with reduced ejection fraction delivered by healthcare professionals across Asia-Pacific, the Middle East and Africa (henceforth referred to as the "Region").

METHODS

We convened a group of cardiologists from across the Region to develop a set of checklists, algorithms, and other practical resources. These resources are based on our experiences, current evidence, and international guidelines.

RESULTS

The HF Toolbox comprises three simplified sets of resources for use in the Emergency Room (ER), hospital and outpatient settings. Resources include admission and discharge checklists, treatment algorithms, recommendations for forming a multidisciplinary team, patient education, and self-management materials, and key performance indicators to monitor whether standards of care are met or maintained, or should be improved.

CONCLUSIONS

The HF Toolbox provides practical resources to simplify the management of patients with HF and to support the formation of HF programs in the Region. The Toolbox is aligned with current guideline recommendations and can support the management of patients from presentation in the ER, through hospital admission to outpatient care.

Prevalence and predictors of physical inactivity levels among Kenyan adults (18-69 years): an analysis of STEPS survey 2015

BACKGROUND

Physical inactivity accounts for more than 3 million deaths worldwide, and is implicated in causing 6% of coronary heart diseases, 7% of diabetes, and 10% of colon or breast cancer. Globally, research has shown that modifying four commonly shared risky behaviours, including poor nutrition, tobacco use, harmful use of alcohol, and physical inactivity, can reduce occurrence of non-communicable diseases (NCDs). Risk factor surveillance through population-based periodic surveys, has been identified as an effective strategy to inform public health interventions in NCD control. The stepwise approach to surveillance (STEPS) survey is one such initiative, and Kenya carried out its first survey in 2015. This study sought to describe the physical inactivity risk factors from the findings of the Kenya STEPS survey.

METHODS

This study employed countrywide representative survey administered between April and June 2015. A three stage cluster sampling design was used to select clusters, households and eligible individuals. All adults between 18 and 69 years in selected households were eligible. Data on demographic, behavioural, and biochemical characteristics were collected. Prevalence of physical inactivity was computed. Logistic regression used to explore factors associated with physical inactivity.

RESULTS

A total of 4500 individuals consented to participate from eligible 6000 households. The mean age was 40.5 (39.9-41.1) years, with 51.3% of the respondents being female. Overall 346 (7.7%) of respondents were classified as physically inactive. Physical inactivity was associated with female gender, middle age (30-49 years), and increasing level of education, increasing wealth index and low levels of High Density Lipoproteins (HDL).

CONCLUSION

A modest prevalence of physical inactivity slightly higher than in neighbouring countries was found in this study. Gender, age, education level and wealth index are evident areas that predict physical inactivity which can be focused on to develop programs that would work towards reducing physical inactivity among adults in Kenya.

Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in Kenya

BACKGROUND

Hypertension is the most important risk factor for cardiovascular diseases and the leading cause of death worldwide. Despite growing evidence that the prevalence of hypertension is rising in sub-Saharan Africa, national data on hypertension that can guide programming are missing for many countries. In this study, we estimated the prevalence of hypertension, awareness, treatment, and control. We further examined the factors associated with hypertension and awareness.

METHOD

We used data from the 2015 Kenya STEPs survey, a national cross-sectional household survey targeting randomly selected people aged 18-69 years. Demographic and behavioral characteristics as well as physical measurements were collected using the World Health Organization's STEPs Survey methodology. Descriptive statistics were used to estimate the prevalence, awareness, treatment and control of hypertension. Multiple logistic regression models were used to identify the determinants of hypertension and awareness.

RESULTS

The study surveyed 4485 participants. The overall age-standardized prevalence for hypertension was 24.5% (95% confidence interval (CI) 22.6% to 26.6%). Among individuals with hypertension, only 15.6% (95% CI 12.4% to 18.9%) were aware of their elevated blood pressure. Among those aware only 26.9%; (95% CI 17.1% to 36.4%) were on treatment and 51.7%; (95% CI 33.5% to 69.9%) among those on treatment had achieved blood pressure control. Factors associated with hypertension were older age (p < 0.001), higher body mass index (BMI) (p < 0.001) and harmful use of alcohol (p < 0.001). Similarly, factors associated with awareness were older age (p = 0.013) and being male (p < 0.001).

CONCLUSION

This study provides the first nationally-representative estimates for hypertension in Kenya. Prevalence among adults is high, with unacceptably low levels of awareness, treatment and control. The results also reveal that men are less aware of their hypertension status hence special attention should focus on this group.

Development of the certificate course in the management of hypertension in Africa (CCMH-Africa): proceedings of the first continental faculty meeting, Nairobi, Kenya, 25-26 February 2018

BACKGROUND

In response to the call by the World Health Organisation to reduce premature deaths from non-communicable diseases by 25% by the year 2025 (25×25), the Pan-African Society of Cardiology (PASCAR), in partnership with several organisations, including the World Heart Federation, have developed an urgent 10-point action plan to improve detection, treatment and control of hypertension in Africa. Priority six of this action plan is to promote a task-shifting/task-sharing approach in the management of hypertension.

AIM

This capacity-building initiative aims to enhance the knowledge, skills and core competences of primary healthcare physicians in the management of hypertension and related complications.

METHODS

In a collaborative approach with the International Society of Hypertension, the British and Irish Hypertension Society, the Public Health Foundation of India and the Centre for Chronic Disease Control, the PASCAR hypertension taskforce held a continental faculty meeting in Kenya on 25 and 26 February 2018 to review and discuss a process of effective contextualisation and implementation of the Indian hypertension management course on the African continent.

RESULTS

A tailored African course in terms of evidence-based learning, up-to-date curriculum and on-the-job training was developed with a robust monitoring and evaluation strategy. The course will be offered on a modular basis with a judicious mix of case studies, group discussions and contact sessions, with great flexibility to accommodate participants' queries.

CONCLUSIONS

Hypertension affects millions of people in Africa and if left untreated is a major cause of heart disease, kidney disease and stroke. CCMH-Africa will train in the next 10 years, 25 000 certified general physicians and 50 000 nurses, capable of adequately managing uncomplicated hypertension, thereby freeing the few available specialists to focus on severe or complicated cases.

Roadmap to achieve 25% hypertension control in Africa by 2025

BACKGROUND AND AIM

The Pan-African Society of Cardiology (PASCAR) has identified hypertension as the highest area of priority for action to reduce heart disease and stroke on the continent. The aim of this PASCAR roadmap on hypertension was to develop practical guidance on how to implement strategies that translate existing knowledge into effective action and improve detection, treatment and control of hypertension and cardiovascular health in sub-Saharan Africa (SSA) by the year 2025.

METHODS

Development of this roadmap started with the creation of a consortium of experts with leadership skills in hypertension. In 2014, experts in different fields, including physicians and non-physicians, were invited to join. Via faceto-face meetings and teleconferences, the consortium made a situation analysis, set a goal, identified roadblocks and solutions to the management of hypertension and customised the World Heart Federation roadmap to Africa.

RESULTS

Hypertension is a major crisis on the continent but very few randomised, controlled trials have been conducted on its management. Also, only 25.8% of the countries have developed or adopted guidelines for the management of hypertension. Other major roadblocks are either government and health-system related or healthcare professional or patient related. The PASCAR hypertension task force identified a 10-point action plan to be implemented by African ministries of health to achieve 25% control of hypertension in Africa by 2025.

CONCLUSIONS

Hypertension affects millions of people in SSA and if left untreated, is a major cause of heart disease and stroke. Very few SSA countries have a clear hypertension policy. This PASCAR roadmap identifies practical and effective solutions that would improve detection, treatment and control of hypertension on the continent and could be implemented as is or adapted to specific national settings.

Cost and affordability of non-communicable disease screening, diagnosis and treatment in Kenya: Patient payments in the private and public sectors

Introduction

The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries, including Kenya, disproportionately to the rest of the world. Our objective was to quantify patient payments to obtain NCD screening, diagnosis, and treatment services in the public and private sector in Kenya and evaluate patients’ ability to pay for the services.

Methods and findings

We collected payment data on cardiovascular diseases, diabetes, breast and cervical cancer, and respiratory diseases from Kenyatta National Hospital, the main tertiary public hospital, and the Kibera South Health Center—a public outpatient facility, and private sector practitioners and hospitals. We developed detailed treatment frameworks for each NCD and used an itemization cost approach to estimate payments. Patient affordability metrics were derived from Kenyan government surveys and national datasets.

Results compare public and private costs in U.S. dollars. NCD screening costs ranged from $4 to $36, while diagnostic procedures, particularly for breast and cervical cancer, were substantially more expensive. Annual hypertension medication costs ranged from $26 to $234 and $418 to $987 in public and private facilities, respectively. Stroke admissions ($1,874 versus $16,711) and dialysis for chronic kidney disease ($5,338 versus $11,024) were among the most expensive treatments. Cervical and breast cancer treatment cost for stage III (curative approach) was about $1,500 in public facilities and more than $7,500 in the private facilities. A large proportion of Kenyans aged 15 to 49 years do not have health insurance, which makes NCD services unaffordable for most people given the overall high cost of services relative to income (average household expenditure per adult is $413 per annum).

Conclusions

There is substantial variation in patient costs between the public and private sectors. Most NCD diagnosis and treatment costs, even in the public sector, represent a substantial economic burden that can result in catastrophic expenditures.

Roadmap to Achieve 25% Hypertension Control in Africa by 2025

BACKGROUND

The Pan-African Society of Cardiology (PASCAR) has identified hypertension as the highest area of priority action to reduce heart disease and stroke on the continent.

OBJECTIVES

The aim of this PASCAR roadmap on hypertension was to develop practical guidance on how to implement strategies that translate existing knowledge into effective action and improve detection, treatment and control of hypertension and cardiovascular health in sub-Saharan Africa (SSA) by the year 2025.

METHODS

Development of this roadmap started with the creation of a consortium of experts with leadership skills in hypertension. In 2014, experts in different fields, including physicians and nonphysicians, were invited to join. Via face-to-face meetings and teleconferences, the consortium made a situation analysis, set a goal, identified roadblocks and solutions to the management of hypertension and customized the World Heart Federation roadmap to Africa.

RESULTS

Hypertension is a major crisis on the continent but very few randomized controlled trials have been conducted on its management. Also, only 25.8% of the countries have developed or adopted guidelines for management of hypertension. Other major roadblocks are either government and health-system related or health care professional or patient related. The PASCAR hypertension task force identified a 10-point action plan to be implemented by African ministries of health to achieve 25% control of hypertension in Africa by 2025.

CONCLUSIONS

Hypertension affects millions of people in SSA and if left untreated, is a major cause of heart disease and stroke. Very few SSA countries have a clear hypertension policy. This PASCAR roadmap identifies practical and effective solutions that would improve detection, treatment and control of hypertension on the continent and could be implemented as is or adapted to specific national settings.

Seven key actions to eradicate rheumatic heart disease in Africa: the Addis Ababa communiqué

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain major causes of heart failure, stroke and death among African women and children, despite being preventable and imminently treatable. From 21 to 22 February 2015, the Social Cluster of the Africa Union Commission (AUC) hosted a consultation with RHD experts convened by the Pan-African Society of Cardiology (PASCAR) in Addis Ababa, Ethiopia, to develop a ‘roadmap’ of key actions that need to be taken by governments to eliminate ARF and eradicate RHD in Africa.

Seven priority areas for action were adopted: (1) create prospective disease registers at sentinel sites in affected countries to measure disease burden and track progress towards the reduction of mortality by 25% by the year 2025, (2) ensure an adequate supply of high-quality benzathine penicillin for the primary and secondary prevention of ARF/RHD, (3) improve access to reproductive health services for women with RHD and other non-communicable diseases (NCD), (4) decentralise technical expertise and technology for diagnosing and managing ARF and RHD (including ultrasound of the heart), (5) establish national and regional centres of excellence for essential cardiac surgery for the treatment of affected patients and training of cardiovascular practitioners of the future, (6) initiate national multi-sectoral RHD programmes within NCD control programmes of affected countries, and (7) foster international partnerships with multinational organsations for resource mobilisation, monitoring and evaluation of the programme to end RHD in Africa.

This Addis Ababa communiqué has since been endorsed by African Union heads of state, and plans are underway to implement the roadmap in order to end ARF and RHD in Africa in our lifetime.

Development of the roadmap and guidelines for the prevention and management of high blood pressure in Africa: Proceedings of the PASCAR Hypertension Task Force meeting: Nairobi, Kenya, 27 October 2014

Africa has one of the fastest growing economies in the world. The economic changes are associated with a health transition characterised by a rise in cardiovascular risk factors and complications, which tend to affect the African population at their age of maximum productivity. Recent data from Africa have highlighted the increasing importance of high blood pressure in this region of the world. This condition is largely underdiagnosed and poorly treated, and therefore leads to stroke, renal and heart failure, and death. Henceforth, African countries are taking steps to develop relevant policies and programmes to address the issue of blood pressure and other cardiovascular risk factors in response to a call by the World Health Organisation (WHO) to reduce premature deaths from non-communicable diseases (NCDs) by 25% by the year 2025 (25 × 25). The World Heart Federation (WHF) has developed a roadmap for global implementation of the prevention and management of raised blood pressure using a health system approach to help realise the 25 × 25 goal set by the WHO. As the leading continental organisation of cardiovascular professionals, the Pan-African Society of Cardiology (PASCAR) aims to contextualise the roadmap framework of the WHF to the African continent through the PASCAR Taskforce on Hypertension. The Taskforce held a workshop in Kenya on 27 October 2014 to discuss a process by which effective prevention and control of hypertension in Africa may be achieved. It was agreed that a set of clinical guidelines for the management of hypertension are needed in Africa. The ultimate goal of this work is to develop a roadmap for implementation of the prevention and management of hypertension in Africa under the auspices of the WHF.