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Rahim FO, Lieber WC, Hertz JT, Wembulua BS, Ndeba PA, Lukelwa RM. Post-election responsibilities for public health in the Democratic Republic of the Congo. Nat Med 2024:10.1038/s41591-024-02932-9. [PMID: 38641751 DOI: 10.1038/s41591-024-02932-9] [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] [Indexed: 04/21/2024]
Affiliation(s)
- Faraan O Rahim
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | | | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Bruce Shinga Wembulua
- University of Kisangani, Kisangani, Democratic Republic of the Congo
- Rutshuru General Hospital, Rutshuru, Democratic Republic of the Congo
| | - Patrick A Ndeba
- Department of Medicine, University of Goma, Goma, Democratic Republic of the Congo
- Provincial Public Health Laboratory of North Kivu AMI-LABO, Goma, Democratic Republic of the Congo
| | - Richard M Lukelwa
- Kintambo General Reference Hospital, Kinshasa, Democratic Republic of the Congo
- Kinshsa School of Public Health, Kinshasa, Democratic Republic of the Congo
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Coaxum LA, Sakita FM, Mlangi JJ, Kweka GL, Tarimo TG, Temu GA, Kilonzo KG, Arthur D, Bettger JP, Thielman NM, Limkakeng AT, Hertz JT. Provider attitudes towards quality improvement for myocardial infarction care in northern Tanzania. PLOS Glob Public Health 2024; 4:e0003051. [PMID: 38574056 PMCID: PMC10994299 DOI: 10.1371/journal.pgph.0003051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 03/03/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Myocardial Infarction (MI) is a leading cause of death worldwide. In high income countries, quality improvement strategies have played an important role in increasing uptake of evidence-based MI care and improving MI outcomes. The incidence of MI in sub-Saharan Africa is rising, but uptake of evidence-based care in northern Tanzania is low. There are currently no published quality improvement interventions from the region. The objective of this study was to determine provider attitudes towards a planned quality improvement intervention for MI care in northern Tanzania. METHODS This study was conducted at a zonal referral hospital in northern Tanzania. A 41-question survey, informed by the Theoretical Framework for Acceptability, was developed by an interdisciplinary team from Tanzania and the United States. The survey, which explored provider attitudes towards MI care improvement, was administered to key provider stakeholders (physicians, nurses, and hospital administrators) using convenience sampling. RESULTS A total of 140 providers were enrolled, including 82 (58.6%) nurses, 56 (40.0%) physicians, and 2 (1.4%) hospital administrators. Most participants worked in the Emergency Department or inpatient medical ward. Providers were interested in participating in a quality improvement project to improve MI care at their facility, with 139 (99.3%) strongly agreeing or agreeing with this statement. All participants agreed or strongly agreed that improvements were needed to MI care pathways at their facility. Though their facility has an MI care protocol, only 88 (62.9%) providers were aware of it. When asked which intervention would be the single-most effective strategy to improve MI care, the two most common responses were provider training (n = 66, 47.1%) and patient education (n = 41, 29.3%). CONCLUSION Providers in northern Tanzania reported strongly positive attitudes towards quality improvement interventions for MI care. Locally-tailored interventions to improve MI should include provider training and patient education strategies.
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Affiliation(s)
- Lauren A. Coaxum
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Francis M. Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Jerome J. Mlangi
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Godfrey L. Kweka
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Tumsifu G. Tarimo
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Gloria A. Temu
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Kajiru G. Kilonzo
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - David Arthur
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Janet P. Bettger
- Department of Health and Rehabilitation Sciences, Temple University, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alexander T. Limkakeng
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
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Grisel B, Adisa O, Sakita FM, Tarimo TG, Kweka GL, Mlangi JJ, Maro AV, Yamamoto M, Coaxum L, Arthur D, Limkakeng AT, Hertz JT. Evaluating the performance of the HEART score in a Tanzanian emergency department. Acad Emerg Med 2024; 31:361-370. [PMID: 38400615 DOI: 10.1111/acem.14872] [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: 11/05/2023] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVE The HEART score successfully risk stratifies emergency department (ED) patients with chest pain in high-income settings. However, this tool has not been validated in low-income countries. METHODS This is a secondary analysis of a prospective observational study that was conducted in a Tanzanian ED from January 2019 through January 2023. Adult patients with chest pain were consecutively enrolled, and their presenting symptoms and medical history were recorded. Electrocardiograms and point-of-care troponin assays were obtained for all participants. Thirty-day follow-up was conducted, assessing for major adverse cardiac events (MACEs), defined as death, myocardial infarction, or coronary revascularization (coronary artery bypass grafting or percutaneous coronary intervention). HEART scores were calculated for all participants. Likelihood ratios, sensitivity, specificity, and negative predictive values (NPVs) were calculated for each HEART cutoff score to predict 30-day MACEs, and area under the curve (AUC) was calculated from the receiver operating characteristic curve. RESULTS Of 927 participants with chest pain, the median (IQR) age was 61 (45.5-74.0) years. Of participants, 216 (23.3%) patients experienced 30-day MACEs, including 163 (17.6%) who died, 48 (5.2%) with myocardial infarction, and 23 (2.5%) with coronary revascularization. The positive likelihood ratio for each cutoff score ranged from 1.023 (95% CI 1.004-1.042; cutoff ≥ 1) to 3.556 (95% CI 1.929-6.555; cutoff ≥ 7). The recommended cutoff of ≥4 to identify patients at high risk of MACEs yielded a sensitivity of 59.4%, specificity of 52.8%, and NPV of 74.7%. The AUC was 0.61. CONCLUSIONS Among patients with chest pain in a Tanzanian ED, the HEART score did not perform as well as in high-income settings. Locally validated risk stratification tools are needed for ED patients with chest pain in low-income countries.
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Affiliation(s)
- Braylee Grisel
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Olanrewaju Adisa
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Tumsifu G Tarimo
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Godfrey L Kweka
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Jerome J Mlangi
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Amedeus V Maro
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Marilyn Yamamoto
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Lauren Coaxum
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - David Arthur
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Alexander T Limkakeng
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Julian T Hertz
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Hertz JT, Sakita FM, Prattipati S, Coaxum L, Tarimo TG, Kweka GL, Mlangi JJ, Stark K, Thielman NM, Bosworth HB, Bettger JP. Improving acute myocardial infarction care in northern Tanzania: barrier identification and implementation strategy mapping. BMC Health Serv Res 2024; 24:393. [PMID: 38549108 PMCID: PMC10979618 DOI: 10.1186/s12913-024-10831-5] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/06/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Evidence-based care for acute myocardial infarction (AMI) reduces morbidity and mortality. Prior studies in Tanzania identified substantial gaps in the uptake of evidence-based AMI care. Implementation science has been used to improve uptake of evidence-based AMI care in high-income settings, but interventions to improve quality of AMI care have not been studied in sub-Saharan Africa. METHODS Purposive sampling was used to recruit participants from key stakeholder groups (patients, providers, and healthcare administrators) in northern Tanzania. Semi-structured in-depth interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview transcripts were coded to identify barriers to AMI care, using the 39 CFIR constructs. Barriers relevant to emergency department (ED) AMI care were retained, and the Expert Recommendations for Implementing Change (ERIC) tool was used to match barriers with Level 1 recommendations for targeted implementation strategies. RESULTS Thirty key stakeholders, including 10 patients, 10 providers, and 10 healthcare administrators were enrolled. Thematic analysis identified 11 barriers to ED-based AMI care: complexity of AMI care, cost of high-quality AMI care, local hospital culture, insufficient diagnostic and therapeutic resources, inadequate provider training, limited patient knowledge of AMI, need for formal implementation leaders, need for dedicated champions, failure to provide high-quality care, poor provider-patient communication, and inefficient ED systems. Seven of these barriers had 5 strong ERIC recommendations: access new funding, identify and prepare champions, conduct educational meetings, develop educational materials, and distribute educational materials. CONCLUSIONS Multiple barriers across several domains limit the uptake of evidence-based AMI care in northern Tanzania. The CFIR-ERIC mapping approach identified several targeted implementation strategies for addressing these barriers. A multi-component intervention is planned to improve uptake of evidence-based AMI care in Tanzania.
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Affiliation(s)
- Julian T Hertz
- Duke Global Health Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Lauren Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | | | | | - Kristen Stark
- Duke Global Health Institute, Duke University School of Medicine, Durham, NC, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Janet P Bettger
- Duke Global Health Institute, Duke University School of Medicine, Durham, NC, USA
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Hertz JT, Stark K, Sakita FM, Mlangi JJ, Kweka GL, Prattipati S, Shayo F, Kaboigora V, Mtui J, Isack MN, Kindishe EM, Ngelengi DJ, Limkakeng AT, Thielman NM, Bloomfield GS, Bettger JP, Tarimo TG. Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention. Ann Glob Health 2024; 90:21. [PMID: 38495415 PMCID: PMC10941691 DOI: 10.5334/aogh.4361] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/23/2024] [Indexed: 03/19/2024] Open
Abstract
Background Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa. Objectives Co-design a quality improvement intervention for AMI care tailored to local contextual factors. Methods An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context. Findings The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education. Conclusion MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.
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Affiliation(s)
- Julian T. Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kristen Stark
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Francis M. Sakita
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University, Moshi, Tanzania
| | | | | | | | - Frida Shayo
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Julius Mtui
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | | | | | - Alexander T. Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Gerald S. Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Janet P. Bettger
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Prattipati S, Tarimo TG, Kweka GL, Mlangi JJ, Samuel D, Sakita FM, Tupetz A, Bettger JP, Thielman NM, Temu G, Hertz JT. Patient and provider perspectives on barriers to myocardial infarction care among persons with human immunodeficiency virus in Tanzania: A qualitative study. Int J STD AIDS 2024; 35:18-24. [PMID: 37703080 DOI: 10.1177/09564624231199507] [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] [Indexed: 09/14/2023]
Abstract
INTRODUCTION People with HIV (PLWH) have an increased risk myocardial infarction (MI), and evidence suggests that MI is under-diagnosed in Tanzania. However, little is known about barriers to MI care among PLWH in the region. METHODS In this qualitative study grounded in phenomenology, semi-structured interviews were conducted in northern Tanzania. Purposive sampling was used to recruit a diverse group of providers who care for PLWH and patients with HIV and electrocardiographic evidence of prior MI. Emergent themes were identified via inductive thematic analysis. RESULTS 24 physician and patient participants were interviewed. Most participants explained MI as caused by emotional shock and were unaware of the association between HIV and increased MI risk. Providers described poor provider training regarding MI, high out-of-pocket costs, and lack of diagnostic equipment and medications. Patients reported little engagement with and limited knowledge of cardiovascular care, despite high engagement with HIV care. Most provider and patient participants indicated that they would prefer to integrate cardiovascular care with routine HIV care. CONCLUSIONS PLWH face many barriers to MI care in Tanzania. There is a need for multifaceted interventions to educate providers and patients, improve access to MI diagnosis, and increase engagement with cardiovascular care among this population.
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Affiliation(s)
| | | | | | | | | | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
| | - Anna Tupetz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Janet P Bettger
- Department of Health and Rehabilitation Sciences, Temple University College of Public Health, Philadelphia, PA, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Gloria Temu
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
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Stark K, O'Leary PRE, Sakita FM, Ford JS, Mmbaga BT, Blass B, Gedion K, Coaxum LA, Rutta A, Galson SW, Rugakingira A, Manavalan P, Bloomfield GS, Hertz JT. Six month incidence of major adverse cardiovascular events among adults with HIV in northern Tanzania: a prospective observational study. BMJ Open 2023; 13:e075275. [PMID: 37984949 PMCID: PMC10660832 DOI: 10.1136/bmjopen-2023-075275] [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: 05/02/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES We aimed to prospectively describe incident cardiovascular events among people living with HIV (PLWH) in northern Tanzania. Secondary aims of this study were to understand non-communicable disease care-seeking behaviour and patient preferences for cardiovascular care and education. DESIGN A prospective observational study. SETTING This study was conducted at the Majengo HIV Care and Treatment Clinic, an outpatient government-funded clinic in Moshi, Tanzania PARTICIPANTS: Adult patients presenting to an HIV clinic for routine care in northern Tanzania were enrolled from 1 September 2020 to 1 March 2021. INTERVENTIONS At enrolment, participants completed a survey and a resting 12-lead ECG was obtained. At 6 month follow-up, a repeat survey regarding interim health events and repeat ECG was obtained. PRIMARY AND SECONDARY OUTCOME MEASURES Interim major adverse cardiovascular events (MACE) were defined by: self-reported interim stroke, self-reported hospitalisation for heart failure, self-reported interim myocardial infarction, interim myocardial infarction by ECG criteria (new pathologic Q waves in two contiguous leads) or death due to cardiovascular disease (CVD). RESULTS Of 500 enrolled participants, 477 (95.4%) completed 6 month follow-up and 3 (0.6%) died. Over the 6 month follow-up period, 11 MACE occurred (3 strokes, 6 myocardial infarctions, 1 heart failure hospitalisation and 1 cardiovascular death), resulting in an incidence rate of 4.58 MACE per 100 person-years. Of participants completing 6 month follow-up, 31 (6.5%) reported a new non-communicable disease diagnosis, including 23 (4.8%) with a new hypertension diagnosis. CONCLUSIONS The incidence of MACE among PLWH in Tanzania is high. These findings are an important preliminary step in understanding the landscape of CVD among PLWH in Tanzania and highlight the need for interventions to reduce cardiovascular risk in this population.
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Affiliation(s)
- Kristen Stark
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Paige R E O'Leary
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - James S Ford
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical University College, Moshi, Tanzania, United Republic of
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania, United Republic of
| | - Beau Blass
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kalipa Gedion
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Lauren A Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alice Rutta
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - Sophie Wolfe Galson
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anzibert Rugakingira
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania, United Republic of
| | - Preeti Manavalan
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Rahim FO, Sakita FM, Coaxum L, Maro AV, Ford JS, Hatter K, Gedion K, Ezad SM, Galson SW, Bloomfield GS, Limkakeng AT, Kessy MS, Mmbaga B, Hertz JT. Longitudinal ECG changes among adults with HIV in Tanzania: A prospective cohort study. PLOS Glob Public Health 2023; 3:e0002525. [PMID: 37878582 PMCID: PMC10599566 DOI: 10.1371/journal.pgph.0002525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/22/2023] [Indexed: 10/27/2023]
Abstract
The prevalence of cardiovascular disease (CVD) is rising among people with HIV (PWH) in sub-Saharan Africa (SSA). Despite the utility of the electrocardiogram (ECG) in screening for CVD, there is limited data regarding longitudinal ECG changes among PWH in SSA. In this study, we aimed to describe ECG changes over a 6-month period in a cohort of PWH in northern Tanzania. Between September 2020 and March 2021, adult PWH were recruited from Majengo HIV Care and Treatment Clinic (MCTC) in Moshi, Tanzania. Trained research assistants surveyed participants and obtained a baseline ECG. Participants then returned to MCTC for a 6-month follow-up, where another ECG was obtained. Two independent physician adjudicators interpreted baseline and follow-up ECGs for rhythm, left ventricular hypertrophy (LVH), bundle branch blocks, ST-segment changes, and T-wave inversion, using standardized criteria. New ECG abnormalities were defined as those that were absent in a patient's baseline ECG but present in their 6-month follow-up ECG. Of 500 enrolled participants, 476 (95.2%) completed follow-up. The mean (± SD) age of participants was 45.7 (± 11.0) years, 351 (73.7%) were female, and 495 (99.8%) were taking antiretroviral therapy. At baseline, 248 (52.1%) participants had one or more ECG abnormalities, the most common of which were LVH (n = 108, 22.7%) and T-wave inversion (n = 89, 18.7%). At six months, 112 (23.5%) participants developed new ECG abnormalities, including 40 (8.0%) cases of new T-wave inversion, 22 (4.6%) cases of new LVH, 12 (2.5%) cases of new ST elevation, and 11 (2.3%) cases of new prolonged QTc. Therefore, new ECG changes were common over a relatively short 6-month period, which suggests that subclinical CVD may develop rapidly in PWH in Tanzania. These data highlight the need for additional studies on CVD in PWH in SSA and the importance of routine CVD screening in this high-risk population.
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Affiliation(s)
- Faraan O. Rahim
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Francis M. Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Lauren Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - James S. Ford
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Kate Hatter
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kalipa Gedion
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Saad M. Ezad
- British Heart Foundation Centre of Research Excellence and NIHR Biomedical Research Centre at the School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London, United Kingdom
| | - Sophie W. Galson
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Gerald S. Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Alexander T. Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Blandina Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
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Lieber WC, Rahim FO, Lartey HSQ, Shah D, Mmbaga BT, Thielman NM, Hertz JT. Capacity building for infectious disease control in Sub-Saharan Africa. Pathog Glob Health 2023:1-3. [PMID: 37853767 DOI: 10.1080/20477724.2023.2272363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Affiliation(s)
| | - Faraan O Rahim
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Henry S Q Lartey
- Department of Environmental Science, University of Cape Coast, Cape Coast, Ghana
| | - Devesh Shah
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
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Roberts JK, Sullivan M, Atwater S, Desai K, Prabhu NK, Hertz JT, Buhr GT, Peyser B, Weigle N. Use of Virtual Interactive Patient Encounters to Prepare First-Year Medical Students for Clinical Practice. Acad Med 2023; 98:1146-1153. [PMID: 37257029 DOI: 10.1097/acm.0000000000005286] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PROBLEM With the dissolution of the Step 2 Clinical Skills exam, medical programs have a greater responsibility to teach and assess clinical skills in the preclerkship years. Clinical teaching this early has traditionally been avoided because of insufficient integration with biomedical sciences, curricular time constraints, and concerns about overwhelming novice learners with clinical learning objectives. To overcome these barriers, the authors created a clinical framework for the biomedical science curriculum by integrating a series of virtual interactive patient (VIP) videos. APPROACH Matriculating first-year medical students were enrolled in a clinically integrated biomedical science course that used VIP videos to teach and assess clinical skills. The VIP videos were enhanced with interactive pop-in windows, and at the conclusion of each video, students performed a clinical documentation task and received immediate feedback. The authors implemented 7 VIP cases during fall 2021 in which first-year medical students wrote the patient care plan, problem representation statement, or clinical reasoning assessment. Student responses were independently evaluated by course faculty using a 4-level scoring scale. The authors calculated the pooled mean scores for each documentation task and examined student feedback. OUTCOMES Seven VIP encounters were assigned to 124 students (mean response rate, 98.5%). Pooled mean scores on the clinical documentation tasks showed that most students were able to achieve levels 3 or 4 when writing the patient care plan (97 [82%] to 113 [94%]), addressing social determinants of health (80 [67%]), writing an accurate problem representation statement (113 [91%] to 117 [94%]), and performing clinical reasoning skills (48 [40%] to 95 [82%]). NEXT STEPS VIP encounters were feasible to produce, effective at integrating course content, successful at assessing student clinical documentation skills, and well received. The authors will continue to produce, implement, and study the VIP as an integrating learning tool in undergraduate medical education.
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Affiliation(s)
- John K Roberts
- J.K. Roberts is associate professor of medicine, Division of Nephrology, Department of Medicine, Duke University Health System, and clinical correlations course director, Duke School of Medicine, Durham, North Carolina
| | - Meghan Sullivan
- M. Sullivan is a medical student, Duke University School of Medicine, Durham, North Carolina
| | - Sierra Atwater
- S. Atwater was a medical student, Duke University School of Medicine, Durham, North Carolina
| | - Katha Desai
- K. Desai was a medical student, Duke University School of Medicine, Durham, North Carolina
| | - Neel K Prabhu
- N.K. Prabhu was a medical student, Duke University School of Medicine, Durham, North Carolina
| | - Julian T Hertz
- J.T. Hertz is assistant professor of emergency medicine, Duke University Health System, and clinical skills training immersion course director, Duke School of Medicine, Durham, North Carolina
| | - Gwendolen T Buhr
- G.T. Buhr is associate professor of medicine, Division of Geriatrics, Department of Medicine, Duke University Health System, Durham, North Carolina
| | - Bruce Peyser
- B. Peyser is professor of medicine, Department of Medicine, Duke University Health System, Durham, North Carolina
| | - Nancy Weigle
- N. Weigle is associate professor in family medicine and community health, Duke University Health System, and clinical skills foundation course director, Duke School of Medicine, Durham, North Carolina
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Sakita FM, O’Leary P, Prattipati S, Kessy MS, Kilonzo KG, Mmbaga BT, Rugakingira AA, Manavalan P, Thielman NM, Samuel D, Hertz JT. Six-month incidence of hypertension and diabetes among adults with HIV in Tanzania: A prospective cohort study. PLOS Glob Public Health 2023; 3:e0001929. [PMID: 37603550 PMCID: PMC10441788 DOI: 10.1371/journal.pgph.0001929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/28/2023] [Indexed: 08/23/2023]
Abstract
Data describing the incidence of hypertension and diabetes among people with HIV in sub-Saharan Africa remain sparse. In this study, adults with HIV were enrolled from a public clinic in Moshi, Tanzania (September 2020-March 2021). At enrollment, a survey was administered to collect information on comorbidities and medication use. Each participant's blood pressure and point-of-care glucose were measured. Baseline hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension at enrollment. Baseline diabetes was defined by self-reported diabetes or hyperglycemia (fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl) at enrollment. At 6-month follow-up, participants' blood pressure and point-of-care glucose were again measured. Incident hypertension was defined by self-report of new hypertension diagnosis or blood pressure ≥140/90 mmHg at follow-up in a participant without baseline hypertension. Incident diabetes was defined as self-report of new diabetes diagnosis or measured hyperglycemia at follow-up in a participant without baseline diabetes. During the study period, 477 participants were enrolled, of whom 310 did not have baseline hypertension and 457 did not have baseline diabetes. At six-month follow-up, 51 participants (95% CI: 38, 67) had new-onset hypertension, corresponding to an incidence of 33 new cases of hypertension per 100 person-years. Participants with incident hypertension at 6-month follow-up were more likely to have a history of alcohol use (90.2% vs. 73.7%, OR = 3.18, 95% CI:1.32-9.62, p = 0.008) and were older (mean age = 46.5 vs. 42.3, p = 0.027). At six-month follow-up, 8 participants (95% CI: 3, 16) had new-onset diabetes, corresponding to an incidence of 3 new cases of diabetes per 100 person-years. In conclusion, the incidence of elevated blood pressure and diabetes among Tanzanians with HIV is higher than what has been reported in high-income settings.
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Affiliation(s)
| | - Paige O’Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sainikitha Prattipati
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | | | | | - Preeti Manavalan
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Dorothy Samuel
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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12
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Moorthy GS, Madut DB, Kilonzo KG, Lwezaula BF, Mbwasi R, Mmbaga BT, Ngocho JS, Saganda W, Bonnewell JP, Carugati M, Egger JR, Hertz JT, Tillekeratne LG, Maze MJ, Maro VP, Crump JA, Rubach MP. Antibacterial Utilization for Febrile Illnesses and Laboratory-Confirmed Bloodstream Infections in Northern Tanzania. Open Forum Infect Dis 2023; 10:ofad448. [PMID: 37663090 PMCID: PMC10468737 DOI: 10.1093/ofid/ofad448] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023] Open
Abstract
Background We describe antibacterial use in light of microbiology data and treatment guidelines for common febrile syndromes in Moshi, Tanzania. Methods We compared data from 2 hospital-based prospective cohort studies, cohort 1 (2011-2014) and cohort 2 (2016-2019), that enrolled febrile children and adults. A study team member administered a standardized questionnaire, performed a physical examination, and collected blood cultures. Participants with bloodstream infection (BSI) were categorized as receiving effective or ineffective therapy based upon antimicrobial susceptibility interpretations. Antibacterials prescribed for treatment of pneumonia, urinary tract infection (UTI), or presumed sepsis were compared with World Health Organization and Tanzania Standard Treatment Guidelines. We used descriptive statistics and logistic regression to describe antibacterial use. Results Among participants, 430 of 1043 (41.2%) and 501 of 1132 (44.3%) reported antibacterial use prior to admission in cohorts 1 and 2, respectively. During admission, 930 of 1043 (89.2%) received antibacterials in cohort 1 and 1060 of 1132 (93.6%) in cohort 2. Inpatient use of ceftriaxone, metronidazole, and ampicillin increased between cohorts (P ≤ .002 for each). BSI was detected in 38 (3.6%) participants in cohort 1 and 47 (4.2%) in cohort 2. Of 85 participants with BSI, 81 (95.3%) had complete data and 52 (64.2%) were prescribed effective antibacterials. Guideline-consistent therapy in cohort 1 and cohort 2 was as follows: pneumonia, 87.4% and 56.8%; UTI, 87.6% and 69.0%; sepsis, 84.4% and 61.2% (P ≤ .001 for each). Conclusions Receipt of antibacterials for febrile illness was common. While guideline-consistent prescribing increased over time, more than one-third of participants with BSI received ineffective antibacterials.
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Affiliation(s)
- Ganga S Moorthy
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Deng B Madut
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Kajiru G Kilonzo
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | | | - Ronald Mbwasi
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - James S Ngocho
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - Wilbrod Saganda
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - John P Bonnewell
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Manuela Carugati
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph R Egger
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - L Gayani Tillekeratne
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael J Maze
- Centre for International Health, University of Otago, Dunedin, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Venance P Maro
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - John A Crump
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Matthew P Rubach
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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13
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Rahim FO, Jain B, Bloomfield GS, Jain P, Rugakingira A, Thielman NM, Sakita F, Hertz JT. A holistic framework to integrate HIV and cardiovascular disease care in sub-Saharan Africa. AIDS 2023; 37:1497-1502. [PMID: 37199570 DOI: 10.1097/qad.0000000000003604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Faraan O Rahim
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, Massachusetts
- Stanford University School of Medicine, Stanford, California
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Pankaj Jain
- Highmark Health, Pittsburgh
- Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | | | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Stanford University School of Medicine, Stanford, California
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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14
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Sakita FM, Prattipati S, Chick J, Samu LP, Maro AV, Coaxum L, Galson SW, Samuel D, Limkakeng AT, O'Leary PR, Kilonzo KG, Thielman NM, Temu G, Hertz JT. Six-month blood pressure and glucose control among HIV-infected adults with elevated blood pressure and hyperglycemia in northern Tanzania: A prospective observational study. PLoS One 2023; 18:e0285472. [PMID: 37155672 PMCID: PMC10166506 DOI: 10.1371/journal.pone.0285472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 04/25/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND People with HIV in sub-Saharan Africa are increasingly developing age-related comorbidities. The purpose of this prospective observational study was to describe 6-month outcomes among Tanzanians with HIV and elevated blood pressure or hyperglycemia under current care pathways. METHODS Adults presenting for routine HIV care were enrolled and underwent blood pressure and blood glucose measurements. Participants with abnormal blood pressure or glucose were referred for further care, as per current guidelines. Participants' blood pressure and point-of-care glucose were re-evaluated during their 6-month follow-up visit. Elevated blood pressure was defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. Hyperglycemia was defined as fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl. An electrocardiogram was obtained at enrollment and at follow-up. Interim myocardial infarction and interim myocardial ischemia were defined as new pathologic Q waves and new T-wave inversions, respectively. RESULTS Of 500 participants, 155 had elevated blood pressure and 17 had hyperglycemia at enrolment. At 6-month follow-up, 7 (4.6%) of 155 participants with elevated blood pressure reported current use of an anti-hypertensive medication, 100 (66.2%) had persistent elevated blood pressure, 12 (7.9%) developed interim myocardial infarction, and 13 (8.6%) developed interim myocardial ischemia. Among 17 participants with hyperglycemia, 9 (56%) had persistent hyperglycemia at 6 months and 2 (12.5%) reported current use of an anti-hyperglycemic medication. CONCLUSIONS Interventions are needed to improve non-communicable disease care pathways among Tanzanians with HIV.
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Affiliation(s)
- Francis M Sakita
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Sainikitha Prattipati
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Jordan Chick
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Linda P Samu
- Health Department, Moshi Municipal Council, Moshi, Tanzania
| | | | - Lauren Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sophie W Galson
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Alexander T Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Paige R O'Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kajiru G Kilonzo
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Gloria Temu
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
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15
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Galson SW, Pesambili M, Vissoci JRN, Manavalan P, Hertz JT, Temu G, Staton CA, Stanifer JW. Hypertension in an Emergency Department Population in Moshi, Tanzania; A Qualitative Study of Barriers to Hypertension Control. PLoS One 2023; 18:e0279377. [PMID: 36608026 PMCID: PMC9821488 DOI: 10.1371/journal.pone.0279377] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Sub-Saharan Africa has a high prevalence of hypertension with a low rate of awareness, treatment adherence, and control. The emergency department (ED) may represent a unique opportunity to improve hypertension screening, awareness, and linkage to care. We conducted a qualitative study among hypertensive patients presenting to the ED and their healthcare providers to determine barriers to hypertension care and control. METHODS In northern Tanzania, between November and December 2017, we conducted three focus group discussions among patients with hypertension presenting to the emergency department and three in-depth interviews among emergency department physicians. In our study, hypertension was defined as a single blood pressure of ≥160/100 mm Hg or a two-time average of ≥140/90 mm Hg. Barriers to care were identified by thematic analysis applying an inductive approach within the framework method. RESULTS We enrolled 24 total patients into three focus groups and performed three in-depth interviews with individual providers. Thematic analysis identified two major domains: 1) patient knowledge, attitudes, and practices, and 2) structural barriers to hypertension care. Four major themes emerged within the knowledge, attitudes, and practices domain, including disease chronicity, provider communication, family support, and fear-based attitudes. Within the structural domain, several themes emerged that identified barriers that impeded hypertension follow-up care and self-management, including cost, access to care, and transportation and wait time. CONCLUSION Patients and physicians identified multiple barriers and facilitators to hypertension care. These perspectives may be helpful to design emergency department-based interventions that target blood pressure control and linkage to outpatient care.
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Affiliation(s)
- Sophie W. Galson
- Duke Emergency Medicine, Duke Global Health Institute, Durham, NC, United States of America
- * E-mail:
| | | | | | - Preeti Manavalan
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Julian T. Hertz
- Duke Emergency Medicine, Duke Global Health Institute, Durham, NC, United States of America
| | - Gloria Temu
- Kilimanjaro Christian Medical Center, Kilimanjaro, Tanzania
| | - Catherine A. Staton
- Duke University Medical Center, Duke Global Health Institute, Durham, NC, United States of America
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Hertz JT, Prattipati S, Kweka GL, Mlangi JJ, Tarimo TG, Mmbaga BT, Thielman NM, Sakita FM, Rubach MP, Bloomfield GS, Manavalan P. Prevalence and predictors of uncontrolled hypertension, diabetes, and obesity among adults with HIV in northern Tanzania. Glob Public Health 2022; 17:3747-3759. [PMID: 35282776 PMCID: PMC9468185 DOI: 10.1080/17441692.2022.2049344] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/19/2022] [Indexed: 02/06/2023]
Abstract
HIV is associated with increased risk of cardiovascular disease, but there has been less study of cardiovascular comorbidities among people with HIV in sub-Saharan Africa. In a cross-sectional observational study, Tanzanian adults presenting for outpatient HIV care completed a questionnaire and underwent weight, height, blood pressure, and blood glucose measurement. Hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension. Uncontrolled hypertension was defined as measured blood pressure ≥140/90 mmHg. Diabetes was defined by fasting glucose ≥126 mg/dl, random glucose ≥200 mg/dl, or self-reported diabetes. Obesity was defined by body mass index ≥30 kg/m2. Multivariate logistic regression was performed to identify predictors of uncontrolled hypertension. Among 500 participants, 173 (34.6%) had hypertension, 21 (4.2%) had diabetes, and 99 (19.8%) were obese. Of those with hypertension, 116 (67.1%) were unaware of their hypertension, and 155 (89.6%) had uncontrolled hypertension. In multivariate analysis, uncontrolled hypertension was associated with older age (OR 1.07, 95% CI: 1.05-1.10, p < 0.001) and higher body mass index (OR 1.17, 95% CI: 1.11-1.22, p < 0.001). Interventions are needed to improve screening and treatment for hypertension, diabetes, and obesity among Tanzanians with HIV.
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Affiliation(s)
- Julian T Hertz
- Duke University School of Medicine, Durham, NC
- Duke Global Health Institute, Durham, NC
| | | | | | | | | | - Blandina T Mmbaga
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan M Thielman
- Duke University School of Medicine, Durham, NC
- Duke Global Health Institute, Durham, NC
| | - Francis M Sakita
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Matthew P Rubach
- Duke University School of Medicine, Durham, NC
- Duke Global Health Institute, Durham, NC
| | - Gerald S Bloomfield
- Duke University School of Medicine, Durham, NC
- Duke Global Health Institute, Durham, NC
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Hertz JT, Sakita FM, Kweka GL, Loring Z, Thielman NM, Temu G, Bartlett JA. Healthcare-seeking behaviour, barriers to care and predictors of symptom improvement among patients with cardiovascular disease in northern Tanzania. Int Health 2022; 14:373-380. [PMID: 31840178 PMCID: PMC9248051 DOI: 10.1093/inthealth/ihz095] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 06/25/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Little is known about healthcare-seeking behaviour and barriers to care for cardiovascular disease (CVD) in sub-Saharan Africa. METHODS Emergency department patients in Tanzania with acute CVD were prospectively enrolled. Questionnaires were administered at enrollment and 30 d later. RESULTS Of 241 patients, 186 (77.2%) had visited another facility for the same illness episode (median symptom duration prior to presentation was 7 d) and 82 (34.0%) reported that they were initially unaware of the potential seriousness of their symptoms. Of the 208 (86.3%) patients completing follow-up, 16 (7.7%) had died, 38 (18.3%) had visited another facility for persistent symptoms, 99 (47.6%) felt they understood their diagnosis, 87 (41.8%) felt they understood their treatment and 11 (7.8%) could identify any of their medications. Predictors of 30 d survival with symptom improvement included medication compliance (p<0.001), understanding the diagnosis (p=0.007), understanding the treatment (p<0.001) and greater CVD knowledge (p=0.008). CONCLUSIONS Patients with CVD in Tanzania usually visit multiple facilities for the same illness episode, typically after prolonged delays. Only a minority understand their diagnosis and treatment, and such understanding is correlated with survival with symptom improvement. Patient-centred interventions are needed to improve the quality of cardiovascular care in Tanzania.
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Affiliation(s)
- Julian T Hertz
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Godfrey L Kweka
- Kilimanjaro Christian Research Institute, PO Box 2236, Moshi, Tanzania
| | - Zak Loring
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
- Duke Clinical Research Institute, 300 W Morgan St, Durham, NC 27701, USA
| | - Nathan M Thielman
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA
| | - Gloria Temu
- Department of Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - John A Bartlett
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA
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Hertz JT, Sakita FM, Kweka GL, Tarimo TG, Goli S, Prattipati S, Bettger JP, Thielman NM, Bloomfield GS. One-Year Outcomes and Factors Associated With Mortality Following Acute Myocardial Infarction in Northern Tanzania. Circ Cardiovasc Qual Outcomes 2022; 15:e008528. [PMID: 35300504 PMCID: PMC9018510 DOI: 10.1161/circoutcomes.121.008528] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about long-term outcomes and uptake of secondary preventative therapies following acute myocardial infarction (AMI) in sub-Saharan Africa. METHODS Consecutive patients presenting with AMI (as defined by the Fourth Universal Definition of AMI Criteria) to a northern Tanzanian referral hospital were enrolled in this prospective observational study. Follow-up surveys assessing mortality, medication use, and rehospitalization were administered at 3, 6, 9, and 12 months following initial presentation, by telephone or in person. Multivariate logistic regression was performed to identify baseline clinical and sociodemographic factors associated with one-year mortality. RESULTS Of 152 enrolled patients with AMI, 5 were lost to one-year follow-up (96.7% retention rate). Mortality rates were 34.9% (53 of 152 participants) during the initial hospitalization, 48.7% (73 of 150 patients) at 3 months, 52.7% (78 of 148 patients) at 6 months, 55.4% (82 of 148 patients) at 9 months, and 59.9% (88 of 147 patients) at one year. Of 59 patients surviving to one-year follow-up, 43 (72.9%) reported persistent anginal symptoms, 5 (8.5%) were taking an antiplatelet, 8 (13.6%) were taking an antihypertensive, 30 (50.8%) had been rehospitalized, and 7 (11.9%) had ever undergone cardiac catheterization. On multivariate analysis, one-year mortality was associated with lack of secondary education (odds ratio, 0.26 [95% CI, 0.11-0.58]; P=0.001), lower body mass index (odds ratio, 0.90 [95% CI, 0.82-0.98]; P=0.015), and higher initial troponin (odds ratio, 1.30 [95% CI, 1.05-1.80]; P=0.052). CONCLUSIONS In northern Tanzania, AMI is associated with high all-cause one-year mortality and use of evidence-based secondary preventative therapies among AMI survivors is low. Interventions are needed to improve AMI care and outcomes.
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Affiliation(s)
- Julian T Hertz
- Division of Emergency Medicine (J.T.H.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania (F.M.S.)
| | - Godfrey L Kweka
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
| | - Tumsifu G Tarimo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
| | - Sumana Goli
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Sainikitha Prattipati
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Janet P Bettger
- Department of Orthopaedic Surgery (J.P.B.), Duke University, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Washington, District of Colombia (J.P.B.)
| | - Nathan M Thielman
- Department of Internal Medicine (N.M.T.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Gerald S Bloomfield
- Division of Cardiology (G.S.B.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC (G.S.B.)
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19
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Pisharody S, Rubach MP, Carugati M, Nicholson WL, Perniciaro JL, Biggs HM, Maze MJ, Hertz JT, Halliday JEB, Allan KJ, Mmbaga BT, Saganda W, Lwezaula BF, Kazwala RR, Cleaveland S, Maro VP, Crump JA. Incidence Estimates of Acute Q Fever and Spotted Fever Group Rickettsioses, Kilimanjaro, Tanzania, from 2007 to 2008 and from 2012 to 2014. Am J Trop Med Hyg 2021; 106:494-503. [PMID: 34929672 PMCID: PMC8832940 DOI: 10.4269/ajtmh.20-1036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/04/2021] [Indexed: 11/30/2022] Open
Abstract
Q fever and spotted fever group rickettsioses (SFGR) are common causes of severe febrile illness in northern Tanzania. Incidence estimates are needed to characterize the disease burden. Using hybrid surveillance—coupling case-finding at two referral hospitals and healthcare utilization data—we estimated the incidences of acute Q fever and SFGR in Moshi, Kilimanjaro, Tanzania, from 2007 to 2008 and from 2012 to 2014. Cases were defined as fever and a four-fold or greater increase in antibody titers of acute and convalescent paired sera according to the indirect immunofluorescence assay of Coxiella burnetii phase II antigen for acute Q fever and Rickettsia conorii (2007–2008) or Rickettsia africae (2012–2014) antigens for SFGR. Healthcare utilization data were used to adjust for underascertainment of cases by sentinel surveillance. For 2007 to 2008, among 589 febrile participants, 16 (4.7%) of 344 and 27 (8.8%) of 307 participants with paired serology had Q fever and SFGR, respectively. Adjusted annual incidence estimates of Q fever and SFGR were 80 (uncertainty range, 20–454) and 147 (uncertainty range, 52–645) per 100,000 persons, respectively. For 2012 to 2014, among 1,114 febrile participants, 52 (8.1%) and 57 (8.9%) of 641 participants with paired serology had Q fever and SFGR, respectively. Adjusted annual incidence estimates of Q fever and SFGR were 56 (uncertainty range, 24–163) and 75 (uncertainty range, 34–176) per 100,000 persons, respectively. We found substantial incidences of acute Q fever and SFGR in northern Tanzania during both study periods. To our knowledge, these are the first incidence estimates of either disease in sub-Saharan Africa. Our findings suggest that control measures for these infections warrant consideration.
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Affiliation(s)
- Sruti Pisharody
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Matthew P Rubach
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina.,Duke Global Health Institute, Duke University, Durham, North Carolina.,Programme in Emerging Infectious Diseases, Duke-National University of Singapore, Singapore.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Manuela Carugati
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - William L Nicholson
- Centers for Disease Control and Prevention, Rickettsial Zoonoses Branch, Atlanta, Georgia
| | - Jamie L Perniciaro
- Centers for Disease Control and Prevention, Rickettsial Zoonoses Branch, Atlanta, Georgia
| | - Holly M Biggs
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Michael J Maze
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Centre for International Health, University of Otago, Dunedin, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Jo E B Halliday
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Kathryn J Allan
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Wilbrod Saganda
- Mawenzi Regional Referral Hospital, Moshi, Tanzania.,Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Bingileki F Lwezaula
- Mawenzi Regional Referral Hospital, Moshi, Tanzania.,Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | | | - Sarah Cleaveland
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Venance P Maro
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - John A Crump
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina.,Duke Global Health Institute, Duke University, Durham, North Carolina.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Centre for International Health, University of Otago, Dunedin, New Zealand.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
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20
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Oyediran IO, Prattipati S, Sakita FM, Kweka GL, Tarimo TG, Peterson T, Loring Z, Limkakeng AT, Bloomfield GS, Hertz JT. The prevalence, management, and thirty-day outcomes of symptomatic atrial fibrillation in a Tanzanian emergency department. Afr J Emerg Med 2021; 11:404-409. [PMID: 34703731 PMCID: PMC8524111 DOI: 10.1016/j.afjem.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/10/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Data describing atrial fibrillation (AF) care in emergency centres (ECs) in sub-Saharan Africa is lacking. We sought to describe the prevalence and outcomes of AF in a Tanzanian EC. Methods In a prospective, observational study, adults presenting with chest pain or shortness of breath to a Tanzanian EC were enrolled from January through October 2019. Participants underwent electrocardiogram testing which were reviewed by two independent physician judges to determine presence of AF. Participants were asked about their medical history and medication use at enrollment, and a follow-up questionnaire was administered via telephone thirty days later to assess mortality, interim stroke, and medication use. Results Of 681 enrolled patients, 53 (7.8%) had AF. The mean age of participants with AF was 68.1, with a standard deviation (sd) of 21.1 years, and 23 of the 53 (43.4%) being male. On presentation, none of the participants found to have AF reported a previous history of AF. The median CHADS-VASC score among participants was 4 with an interquartile range (IQR) of 2-4. No participants were taking an anticoagulant at baseline. On index presentation, 49 (92.5%) participants with AF were hospitalised with 52 (98.1%) participants completing 30-day follow-up. 18 (34%) participants died, and 5 (9.6%) suffered a stroke. Of the surviving 31 participants with AF and a CHADS-VASC score ≥ 2, none were taking other anti-coagulants at 30 days. Compared to participants without AF, participants with AF were more likely to be hospitalised (OR 5.25, 95% CI 2.10-17.95, p < 0.001), more likely to die within thirty days (OR 1.93, 95% CI 1.03-3.50, p = 0.031), and more likely to suffer a stroke within thirty days (OR 5.91, 95% CI 1.76-17.28, p < 0.001). Discussion AF is common in a Tanzanian EC, with thirty-day mortality being high, but use of evidence-based therapies is rare. There is an opportunity to improve AF care and outcomes in Tanzania. In a Tanzanian emergency centre, atrial fibrillation was common but patient awareness of their condition was low Use of anticoagulants among patients with atrial fibrillation was rare both before and after hospital presentation Following hospital presentation, thirty-day mortality and stroke rates among patients with atrial fibrillation were high
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21
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Prattipati S, Mlangi JJ, Tarimo TG, Kweka GL, Thielman NM, Bettger JP, Mmbaga BT, Sakita FM, Hertz JT. Knowledge, attitudes, and preventive practices regarding ischemic heart disease among HIV-positive individuals in northern Tanzania. Trop Med Int Health 2021; 26:1652-1658. [PMID: 34637597 PMCID: PMC11012094 DOI: 10.1111/tmi.13690] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe knowledge, attitudes, and practices (KAP) regarding ischemic heart disease (IHD) among adults with HIV in Tanzania. METHODS Adults presenting for routine HIV care at a clinic in northern Tanzania were consecutively enrolled and were administered a standardised KAP survey. For each participant, an IHD knowledge score was calculated by tallying correct answers to the IHD knowledge questions, with maximum score 10. Individual 5-year risk of cardiovascular event was calculated using the Harvard NHANES model. Associations between participant characteristics and IHD knowledge scores were assessed via Welch's t-test. RESULTS Among the 500 participants, the mean (SD) age was 45.3 (11.4) years and 139 (27.8%) were males. Most participants recognised high blood pressure (n = 313, 62.6%) as a risk factor for IHD, but fewer identified diabetes as a risk factor (n = 241, 48.2%), or knew that aspirin reduces the risk of a secondary cardiovascular event (n = 73, 14.6%). Higher IHD knowledge score was associated with post-primary education (mean 6.27 vs. 5.35, p = 0.001) and with >10% 5-year risk of cardiovascular event (mean 5.97 vs. 5.41, p = 0.045). Most participants believed there were things they could do to reduce their chances of having a heart attack (n = 361, 72.2%). While participants indicated that they adhered to their prescribed medications (n = 488, 97.6%), only 106 (21.2%) attended regular health check-ups. CONCLUSION Efforts are needed to improve gaps in IHD knowledge, and increase uptake of cardiovascular preventative practices among Tanzanian adults with HIV.
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Affiliation(s)
| | | | | | | | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Janet P Bettger
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Washington, District of Colombia, USA
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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22
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Park SE, Pham DT, Pak GD, Panzner U, Maria Cruz Espinoza L, von Kalckreuth V, Im J, Mogeni OD, Schütt-Gerowitt H, Crump JA, Breiman RF, Adu-Sarkodie Y, Owusu-Dabo E, Rakotozandrindrainy R, Bassiahi Soura A, Aseffa A, Gasmelseed N, Sooka A, Keddy KH, May J, Aaby P, Biggs HM, Hertz JT, Montgomery JM, Cosmas L, Olack B, Fields B, Sarpong N, Razafindrabe TJL, Raminosoa TM, Kabore LP, Sampo E, Teferi M, Yeshitela B, El Tayeb MA, Krumkamp R, Dekker DM, Jaeger A, Tall A, Gassama A, Niang A, Bjerregaard-Andersen M, Løfberg SV, Deerin JF, Park JK, Konings F, Carey ME, Van Puyvelde S, Ali M, Clemens J, Dougan G, Baker S, Marks F. The genomic epidemiology of multi-drug resistant invasive non-typhoidal Salmonella in selected sub-Saharan African countries. BMJ Glob Health 2021; 6:bmjgh-2021-005659. [PMID: 34341020 PMCID: PMC8330565 DOI: 10.1136/bmjgh-2021-005659] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/06/2021] [Indexed: 01/23/2023] Open
Abstract
Background Invasive non-typhoidal Salmonella (iNTS) is one of the leading causes of bacteraemia in sub-Saharan Africa. We aimed to provide a better understanding of the genetic characteristics and transmission patterns associated with multi-drug resistant (MDR) iNTS serovars across the continent. Methods A total of 166 iNTS isolates collected from a multi-centre surveillance in 10 African countries (2010–2014) and a fever study in Ghana (2007–2009) were genome sequenced to investigate the geographical distribution, antimicrobial genetic determinants and population structure of iNTS serotypes–genotypes. Phylogenetic analyses were conducted in the context of the existing genomic frameworks for various iNTS serovars. Population-based incidence of MDR-iNTS disease was estimated in each study site. Results Salmonella Typhimurium sequence-type (ST) 313 and Salmonella Enteritidis ST11 were predominant, and both exhibited high frequencies of MDR; Salmonella Dublin ST10 was identified in West Africa only. Mutations in the gyrA gene (fluoroquinolone resistance) were identified in S. Enteritidis and S. Typhimurium in Ghana; an ST313 isolate carrying blaCTX-M-15 was found in Kenya. International transmission of MDR ST313 (lineage II) and MDR ST11 (West African clade) was observed between Ghana and neighbouring West African countries. The incidence of MDR-iNTS disease exceeded 100/100 000 person-years-of-observation in children aged <5 years in several West African countries. Conclusions We identified the circulation of multiple MDR iNTS serovar STs in the sampled sub-Saharan African countries. Investment in the development and deployment of iNTS vaccines coupled with intensified antimicrobial resistance surveillance are essential to limit the impact of these pathogens in Africa.
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Affiliation(s)
- Se Eun Park
- International Vaccine Institute, Seoul, Republic of Korea.,Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
| | - Duy Thanh Pham
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Gi Deok Pak
- International Vaccine Institute, Seoul, Republic of Korea
| | - Ursula Panzner
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | - Justin Im
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Heidi Schütt-Gerowitt
- International Vaccine Institute, Seoul, Republic of Korea.,Institute of Medical Microbiology, University of Cologne, Cologne, Germany
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand.,Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Robert F Breiman
- Centers for Disease Control and Prevention, KEMRI Complex, Nairobi, Kenya.,Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Yaw Adu-Sarkodie
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.,Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana
| | - Ellis Owusu-Dabo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.,Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana
| | | | - Abdramane Bassiahi Soura
- Institut Supérieur des Sciences de la Population, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Nagla Gasmelseed
- Faculty of Medicine, University of Gezira, Wad Medani, Sudan.,Faculty of Science, University of Hafr Al Batin, Hafr Albatin, Saudi Arabia
| | - Arvinda Sooka
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Karen H Keddy
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jürgen May
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research, Braunschweig, Germany
| | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau.,Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Holly M Biggs
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Julian T Hertz
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Joel M Montgomery
- Centers for Disease Control and Prevention, KEMRI Complex, Nairobi, Kenya
| | - Leonard Cosmas
- Centers for Disease Control and Prevention, KEMRI Complex, Nairobi, Kenya
| | | | - Barry Fields
- Centers for Disease Control and Prevention, KEMRI Complex, Nairobi, Kenya
| | - Nimako Sarpong
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.,German Center for Infection Research, Braunschweig, Germany
| | | | | | | | | | | | | | | | - Ralf Krumkamp
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research, Braunschweig, Germany
| | - Denise Myriam Dekker
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research, Braunschweig, Germany
| | - Anna Jaeger
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research, Braunschweig, Germany
| | - Adama Tall
- Institute Pasteur de Dakar, Dakar, Senegal
| | - Amy Gassama
- Institute Pasteur de Dakar, Dakar, Senegal.,Université Cheikh Anta Diop de Dakar, Dakar, Senegal
| | | | - Morten Bjerregaard-Andersen
- Bandim Health Project, Bissau, Guinea-Bissau.,Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Sandra Valborg Løfberg
- Bandim Health Project, Bissau, Guinea-Bissau.,Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | | | - Jin Kyung Park
- International Vaccine Institute, Seoul, Republic of Korea
| | - Frank Konings
- International Vaccine Institute, Seoul, Republic of Korea
| | - Megan E Carey
- Department of Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Sandra Van Puyvelde
- Medicine, Cambridge University, Cambridge, UK.,Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John Clemens
- International Vaccine Institute, Seoul, Republic of Korea.,International Centre for Diarrheal Disease Research, Dhaka, Bangladesh.,University of California, Fielding School of Public Health, Los Angeles, California, USA
| | - Gordon Dougan
- Department of Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
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23
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Goli S, Sakita FM, Kweka GL, Tarimo TG, Temu G, Thielman NM, Bettger JP, Bloomfield GS, Limkakeng AT, Hertz JT. Thirty-day outcomes and predictors of mortality following acute myocardial infarction in northern Tanzania: A prospective observational cohort study. Int J Cardiol 2021; 342:23-28. [PMID: 34364908 DOI: 10.1016/j.ijcard.2021.08.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is a rising burden of myocardial infarction (MI) within sub-Saharan Africa. Prospective studies of detailed MI outcomes in the region are lacking. METHODS Adult patients with confirmed MI from a prospective surveillance study in northern Tanzania were enrolled in a longitudinal cohort study after baseline health history, medication use, and sociodemographic data were obtained. Thirty days following hospital presentation, symptom status, rehospitalizations, medication use, and mortality were assessed via telephone or in-person interviews using a standardized follow-up questionnaire. Multivariate logistic regression was performed to identify baseline predictors of thirty-day mortality. RESULTS Thirty-day follow-up was achieved for 150 (98.7%) of 152 enrolled participants. Of these, 85 (56.7%) survived to thirty-day follow-up. Of the surviving participants, 71 (83.5%) reported persistent anginal symptoms, four (4.7%) reported taking aspirin regularly, seven (8.2%) were able to identify MI as the reason for their hospitalization, and 17 (20.0%) had unscheduled rehospitalizations. Self-reported history of diabetes at baseline (OR 0.32, 95% CI 0.10-0.89, p = 0.04), self-reported history of hypertension at baseline (OR 0.34, 95% CI 0.15-0.74, p = 0.01), and antiplatelet use at initial presentation (OR 0.19, 95% CI 0.04-0.65, p = 0.02) were all associated with lower odds of thirty-day mortality. CONCLUSIONS In northern Tanzania, thirty-day outcomes following acute MI are poor, and mortality is associated with self-awareness of comorbidities and medication usage. Further investigation is needed to develop interventions to improve care and outcomes of MI in Tanzania.
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Affiliation(s)
- Sumana Goli
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA.
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Godfrey L Kweka
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Tumsifu G Tarimo
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Gloria Temu
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Nathan M Thielman
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA; Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Janet P Bettger
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA; Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Gerald S Bloomfield
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA; Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
| | | | - Julian T Hertz
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA; Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
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24
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Hertz JT, Madut DB, Rubach MP, William G, Crump JA, Galson SW, Maro VP, Bloomfield GS, Limkakeng AT, Temu G, Thielman NM, Sakita FM. Incidence of Acute Myocardial Infarction in Northern Tanzania: A Modeling Approach Within a Prospective Observational Study. J Am Heart Assoc 2021; 10:e021004. [PMID: 34320841 PMCID: PMC8475708 DOI: 10.1161/jaha.121.021004] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Rigorous incidence data for acute myocardial infarction (AMI) in sub‐Saharan Africa are lacking. Consequently, modeling studies based on limited data have suggested that the burden of AMI and AMI‐associated mortality in sub‐Saharan Africa is lower than in other world regions. Methods and Results We estimated the incidence of AMI in northern Tanzania in 2019 by integrating data from a prospective surveillance study (681 participants) and a community survey of healthcare‐seeking behavior (718 participants). In the surveillance study, adults presenting to an emergency department with chest pain or shortness of breath were screened for AMI with ECG and troponin testing. AMI was defined by the Fourth Universal Definition of AMI criteria. Mortality was assessed 30 days following enrollment via in‐person or telephone interviews. In the cluster‐based community survey, adults in northern Tanzania were asked where they would present for chest pain or shortness of breath. Multipliers were applied to account for AMI cases that would have been missed by our surveillance methods. The estimated annual incidence of AMI was 172 (207 among men and 139 among women) cases per 100 000 people. The age‐standardized annual incidence was 211 (263 among men and 170 among women) per 100 000 people. The estimated annual incidence of AMI‐associated mortality was 87 deaths per 100 000 people, and the age‐standardized annual incidence was 102 deaths per 100 000 people. Conclusions The incidence of AMI and AMI‐associated mortality in northern Tanzania is much higher than previously estimated and similar to that observed in high‐income countries.
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Affiliation(s)
- Julian T Hertz
- Duke University School of Medicine Durham NC.,Duke Global Health Institute Durham NC
| | | | - Matthew P Rubach
- Duke University School of Medicine Durham NC.,Duke Global Health Institute Durham NC
| | | | - John A Crump
- Otago Global Health Institute Dunedin New Zealand
| | | | | | - Gerald S Bloomfield
- Duke University School of Medicine Durham NC.,Duke Global Health Institute Durham NC
| | | | - Gloria Temu
- Kilimanjaro Christian Medical Centre Moshi Tanzania
| | - Nathan M Thielman
- Duke University School of Medicine Durham NC.,Duke Global Health Institute Durham NC
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25
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Toy T, Pak GD, Duc TP, Campbell JI, El Tayeb MA, Von Kalckreuth V, Im J, Panzner U, Cruz Espinoza LM, Eibach D, Dekker DM, Park SE, Jeon HJ, Konings F, Mogeni OD, Cosmas L, Bjerregaard-Andersen M, Gasmelseed N, Hertz JT, Jaeger A, Krumkamp R, Ley B, Thriemer K, Kabore LP, Niang A, Raminosoa TM, Sampo E, Sarpong N, Soura A, Owusu-Dabo E, Teferi M, Yeshitela B, Poppert S, May J, Kim JH, Chon Y, Park JK, Aseffa A, Breiman RF, Schütt-Gerowitt H, Aaby P, Adu-Sarkodie Y, Crump JA, Rakotozandrindrainy R, Meyer CG, Sow AG, Clemens JD, Wierzba TF, Baker S, Marks F. Multicountry Distribution and Characterization of Extended-spectrum β-Lactamase-associated Gram-negative Bacteria From Bloodstream Infections in Sub-Saharan Africa. Clin Infect Dis 2020; 69:S449-S458. [PMID: 31665776 PMCID: PMC6821266 DOI: 10.1093/cid/ciz450] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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] [Indexed: 12/20/2022] Open
Abstract
Background Antimicrobial resistance (AMR) is a major global health concern, yet, there are noticeable gaps in AMR surveillance data in regions such as sub-Saharan Africa. We aimed to measure the prevalence of extended-spectrum β-lactamase (ESBL) producing Gram-negative bacteria in bloodstream infections from 12 sentinel sites in sub-Saharan Africa. Methods Data were generated during the Typhoid Fever Surveillance in Africa Program (TSAP), in which standardized blood cultures were performed on febrile patients attending 12 health facilities in 9 sub-Saharan African countries between 2010 and 2014. Pathogenic bloodstream isolates were identified at the sites and then subsequently confirmed at a central reference laboratory. Antimicrobial susceptibility testing, detection of ESBL production, and conventional multiplex polymerase chain reaction (PCR) testing for genes encoding for β-lactamase were performed on all pathogens. Results Five hundred and five pathogenic Gram-negative bloodstream isolates were isolated during the study period and available for further characterization. This included 423 Enterobacteriaceae. Phenotypically, 61 (12.1%) isolates exhibited ESBL activity, and genotypically, 47 (9.3%) yielded a PCR amplicon for at least one of the screened ESBL genes. Among specific Gram-negative isolates, 40 (45.5%) of 88 Klebsiella spp., 7 (5.7%) of 122 Escherichia coli, 6 (16.2%) of 37 Acinetobacter spp., and 2 (1.3%) of 159 of nontyphoidal Salmonella (NTS) showed phenotypic ESBL activity. Conclusions Our findings confirm the presence of ESBL production among pathogens causing bloodstream infections in sub-Saharan Africa. With few alternatives for managing ESBL-producing pathogens in the African setting, measures to control the development and proliferation of AMR organisms are urgently needed.
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Affiliation(s)
- Trevor Toy
- International Vaccine Institute, Seoul, South Korea
| | - Gi Deok Pak
- International Vaccine Institute, Seoul, South Korea
| | - Trung Pham Duc
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - James I Campbell
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Justin Im
- International Vaccine Institute, Seoul, South Korea
| | | | | | - Daniel Eibach
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Denise Myriam Dekker
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research, Hamburg-Borstel-Lübeck, Germany
| | - Se Eun Park
- International Vaccine Institute, Seoul, South Korea
| | - Hyon Jin Jeon
- International Vaccine Institute, Seoul, South Korea.,Department of Medicine, Cambridge University, United Kingdom
| | | | - Ondari D Mogeni
- International Vaccine Institute, Seoul, South Korea.,Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Nairobi
| | - Leonard Cosmas
- Centers for Disease Control and Prevention, KEMRI Complex, Nairobi, Kenya
| | - Morten Bjerregaard-Andersen
- Bandim Health Project, Bissau, Guinea-Bissau.,Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Nagla Gasmelseed
- Faculty of Medicine, University of Gezira, Wad Medani, Sudan.,Faculty of Science, University of Hafr Al Batin, Saudi Arabia
| | - Julian T Hertz
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina
| | - Anna Jaeger
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Ralf Krumkamp
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Benedikt Ley
- International Vaccine Institute, Seoul, South Korea.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia
| | - Kamala Thriemer
- International Vaccine Institute, Seoul, South Korea.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia
| | | | | | | | - Emmanuel Sampo
- Institut Supérieur des Sciences de la Population, University of Ouagadougou, Burkina Faso
| | - Nimako Sarpong
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology (KNUST), Ghana
| | - Abdramane Soura
- Institut Supérieur des Sciences de la Population, University of Ouagadougou, Burkina Faso
| | - Ellis Owusu-Dabo
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology (KNUST), Ghana.,Department of Global and International Health, School of Public Health, KNUST, Kumasi, Ghana
| | | | | | - Sven Poppert
- Infectious Diseases Department, University Hospital Eppendorf, Hamburg, Germany
| | - Jürgen May
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research, Hamburg-Borstel-Lübeck, Germany
| | - Jerome H Kim
- International Vaccine Institute, Seoul, South Korea
| | - Yun Chon
- International Vaccine Institute, Seoul, South Korea
| | | | | | - Robert F Breiman
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Nairobi.,Global Health Institute, Emory University, Atlanta, Georgia
| | - Heidi Schütt-Gerowitt
- International Vaccine Institute, Seoul, South Korea.,Institute of Medical Microbiology, University of Cologne, Germany
| | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau.,Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Yaw Adu-Sarkodie
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology (KNUST), Ghana.,Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - John A Crump
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina.,Duke Global Health Institute, Duke University, Durham, North Carolina.,Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | - Christian G Meyer
- Institute of Tropical Medicine, Eberhard-Karls University Tübingen, Germany.,Duy Tan University, Da Nang, Vietnam
| | - Amy Gassama Sow
- Institute Pasteur de Dakar, Senegal.,Université Cheikh Anta Diop de Dakar, Senegal
| | - John D Clemens
- International Centre for Diarrheal Disease Research, Dhaka, Bangladesh.,University of California, Fielding School of Public Health, Los Angeles.,School of Medicine, Korea University, Seoul, South Korea
| | | | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Department of Medicine, Cambridge University, United Kingdom
| | - Florian Marks
- International Vaccine Institute, Seoul, South Korea.,Department of Medicine, Cambridge University, United Kingdom
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Hertz JT, Sakita FM, Kweka GL, Bloomfield GS, Bartlett JA, Tarimo TG, Temu G, Bettger JP, Thielman NM. Effect of a Triage-Based Screening Protocol on Diagnosis and Treatment of Acute Coronary Syndrome in a Tanzanian Emergency Department: A Prospective Pre-Post Study. J Am Heart Assoc 2020; 9:e016501. [PMID: 32772764 PMCID: PMC7660831 DOI: 10.1161/jaha.120.016501] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Evidence suggests that acute coronary syndrome (ACS) is underdiagnosed in sub-Saharan Africa. Triage-based interventions have improved ACS diagnosis and management in high-income settings but have not been evaluated in sub-Saharan African emergency departments (EDs). Our objective was to estimate the effect of a triage-based screening protocol on ACS diagnosis and care in a Tanzanian ED. Methods and Results All adults presenting to a Tanzanian ED with chest pain or shortness of breath were prospectively enrolled. Treatments and clinician-documented diagnoses were observed and recorded. In the preintervention phase (August 2018 through January 2019), ACS testing and treatment were dictated by physician discretion, as per usual care. A triage-based protocol was then introduced, and in the postintervention phase (January 2019 through October 2019), research assistants performed ECG and point-of-care troponin I testing on all patients with chest pain or shortness of breath upon ED arrival. Pre-post analyses compared ACS care between phases. Of 1020 total participants (339 preintervention phase, 681 postintervention phase), mean (SD) age was 58.9 (19.4) years. Six (1.8%) preintervention participants were diagnosed with ACS, versus 83 (12.2%) postintervention participants (odds ratio [OR], 7.51; 95% CI, 3.52-19.7; P<0.001). Among all participants, 3 (0.9%) preintervention participants received aspirin, compared with 50 (7.3%) postintervention participants (OR, 8.45; 95% CI, 3.07-36.13; P<0.001). Conclusions Introduction of a triage-based ACS screening protocol in a Tanzanian ED was associated with significant increases in ACS diagnoses and aspirin administration. Additional research is needed to determine the effect of ED-based interventions on ACS care and clinical end points in sub-Saharan Africa.
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Affiliation(s)
- Julian T Hertz
- Department of Surgery Duke University School of Medicine Durham NC.,Duke Global Health Institute Duke University Durham NC
| | - Francis M Sakita
- Department of Emergency Medicine Kilimanjaro Christian Medical Centre Moshi Tanzania.,Kilimanjaro Christian Medical University College Moshi Tanzania
| | | | - Gerald S Bloomfield
- Duke Global Health Institute Duke University Durham NC.,Department of Medicine Duke University School of Medicine Durham NC
| | - John A Bartlett
- Duke Global Health Institute Duke University Durham NC.,Kilimanjaro Christian Medical University College Moshi Tanzania.,Department of Medicine Duke University School of Medicine Durham NC
| | | | - Gloria Temu
- Kilimanjaro Christian Medical University College Moshi Tanzania.,Department of Medicine Kilimanjaro Christian Medical Centre Moshi Tanzania
| | - Janet P Bettger
- Duke Global Health Institute Duke University Durham NC.,Department of Orthopaedic Surgery Duke University School of Medicine Durham NC
| | - Nathan M Thielman
- Duke Global Health Institute Duke University Durham NC.,Department of Medicine Duke University School of Medicine Durham NC
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27
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Hertz JT, Sakita FM, Kweka GL, Limkakeng AT, Galson SW, Ye JJ, Tarimo TG, Temu G, Thielman NM, Bettger JP, Bartlett JA, Mmbaga BT, Bloomfield GS. Acute myocardial infarction under-diagnosis and mortality in a Tanzanian emergency department: A prospective observational study. Am Heart J 2020; 226:214-221. [PMID: 32619815 DOI: 10.1016/j.ahj.2020.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Growing evidence suggests that under-diagnosis of acute myocardial infarction (AMI) may be common in sub-Saharan Africa. Prospective studies of routine AMI screening among patients presenting to emergency departments in sub-Saharan Africa are lacking. Our objective was to determine the prevalence of AMI among patients in a Tanzanian emergency department. METHODS In a prospective observational study, consecutive adult patients presenting with chest pain or shortness of breath to a referral hospital emergency department in northern Tanzania were enrolled. Electrocardiogram (ECG) and troponin testing were performed for all participants to diagnose AMI types according to the Fourth Universal Definition. All ECGs were interpreted by two independent physician judges. ECGs suggesting ST-elevation myocardial infarction (STEMI) were further reviewed by additional judges. Mortality was assessed 30 days following enrollment. RESULTS Of 681 enrolled participants, 152 (22.3%) had AMI, including 61 STEMIs and 91 non-STEMIS (NSTEMIs). Of AMI patients, 91 (59.9%) were male, mean (SD) age was 61.2 (18.5) years, and mean (SD) duration of symptoms prior to presentation was 6.6 (12.2) days. In the emergency department, 35 (23.0%) AMI patients received aspirin and none received thrombolytics. Of 150 (98.7%) AMI patients completing 30-day follow-up, 65 (43.3%) had died. CONCLUSIONS In a northern Tanzanian emergency department, AMI is common, rarely treated with evidence-based therapies, and associated with high mortality. Interventions are needed to improve AMI diagnosis, care, and outcomes.
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28
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Manavalan P, Madut DB, Hertz JT, Thielman NM, Okeke NL, Mmbaga BT, Watt MH. Hypertension burden and challenges across the hypertension treatment cascade among adults enrolled in HIV care in northern Tanzania. J Clin Hypertens (Greenwich) 2020; 22:1518-1522. [PMID: 32652868 DOI: 10.1111/jch.13929] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/17/2020] [Accepted: 05/30/2020] [Indexed: 12/15/2022]
Abstract
Failure to address hypertension among people living with HIV (PLWH) may undermine the significant progress made toward reducing mortality among this high-risk population in sub-Saharan Africa (SSA). Here, the authors report hypertension prevalence, diagnosis, and treatment among patients enrolled in HIV care in Tanzania. Patients attending an HIV clinic were consecutively screened for hypertension. Hypertension was defined as follows: a single blood pressure measurement ≥160 mm Hg systolic or ≥100 mm Hg diastolic, two measurements at separate visits ≥140 mm Hg systolic or ≥90 mm Hg diastolic, or self-reported hypertension diagnosis. The authors screened 555 patients, and 19.6% met hypertension criteria. Among a subset of 91 hypertensive participants, 44 (48.4%) reported previous blood pressure measurements, 32 (35.2%) were aware of diagnosis, 10 (11.0%) reported current antihypertensive use, and none had controlled blood pressure. Addressing barriers along the hypertension treatment cascade must be a top priority to improve cardiovascular outcomes among PLWH in SSA.
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Affiliation(s)
- Preeti Manavalan
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Deng B Madut
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Division of Emergency Medicine, Duke University, Durham, NC, USA
| | - Nathan M Thielman
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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29
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Hertz JT, Madut DB, Tesha RA, William G, Simmons RA, Galson SW, Maro VP, Crump JA, Rubach MP. Self-medication with non-prescribed pharmaceutical agents in an area of low malaria transmission in northern Tanzania: a community-based survey. Trans R Soc Trop Med Hyg 2020; 113:183-188. [PMID: 30597114 PMCID: PMC6432801 DOI: 10.1093/trstmh/try138] [Citation(s) in RCA: 8] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/22/2018] [Accepted: 12/06/2018] [Indexed: 11/29/2022] Open
Abstract
Background Self-treatment with antimicrobials is common in sub-Saharan Africa. Little is known about the prevalence of this practice where malaria transmission intensity is low, and little is known about the prevalence of self-treatment with other medications such as antihypertensives and antihyperglycemics. Methods A two-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified healthcare decision-makers from randomly selected households were asked to report instances of self-medication without a prescription in the preceding year. Associations between self-treatment and sociodemographic characteristics were assessed with Pearson’s chi-squared and the Student’s t-test. Results A total of 718 participants completed the survey, and 344 (47.9%) reported any household member obtaining medication without a prescription. Of these, 85 (11.8%) obtained an antimicrobial and four (0.6%) obtained an antihypertensive or antihyperglycemic. Of respondents reporting self-treatment, 306 (89.0%) selected the medication themselves. Self-treatment with antimicrobials was associated with post-primary education (OR 1.95, 95% CI 1.22–3.16, p=0.005), younger age (43.1 vs 48.7 years, p=0.007) and higher socioeconomic status score (0.42 vs 0.34, p=0.023). Conclusions Self-treatment with antimicrobials in an area of low malaria transmission intensity was uncommon and self-treatment with antihypertensives and antihyperglycemics was rare.
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Affiliation(s)
- Julian T Hertz
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, USA
| | - Deng B Madut
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, USA
| | | | | | - Ryan A Simmons
- Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC, USA
| | - Sophie W Galson
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, USA
| | | | - John A Crump
- Otago Global Health Institute, University of Otago, Dunedin, New Zealand
| | - Matthew P Rubach
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, USA
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30
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Hertz JT, Kweka GL, Manavalan P, Watt MH, Sakita FM. Provider-perceived barriers to diagnosis and treatment of acute coronary syndrome in Tanzania: a qualitative study. Int Health 2020; 12:148-154. [PMID: 31329876 PMCID: PMC7017879 DOI: 10.1093/inthealth/ihz061] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 05/13/2019] [Revised: 06/04/2019] [Accepted: 06/06/2019] [Indexed: 12/14/2022] Open
Abstract
Background The incidence of acute coronary syndrome (ACS) is growing across sub-Saharan Africa and many healthcare systems are ill-equipped for this growing burden. Evidence suggests that healthcare providers may be underdiagnosing and undertreating ACS, leading to poor health outcomes. The goal of this study was to examine provider perspectives on barriers to ACS care in Tanzania in order to identify opportunities for interventions to improve care. Methods Semistructured in-depth interviews were conducted with physicians and clinical officers from emergency departments and outpatient departments in northern Tanzania. Thematic analysis was conducted using an iterative cycle of coding and consensus building. Results The 11 participants included six physicians and five clinical officers from health centers, community hospitals and one referral hospital. Providers identified barriers related to providers, systems and patients. Provider-related barriers included inadequate training regarding ACS and poor application of textbook-based knowledge. System-related barriers included lack of diagnostic equipment, unavailability of treatments, referral system delays, lack of data regarding disease burden, absence of locally relevant guidelines and cost of care. Patient-related barriers included inadequate ACS knowledge, inappropriate healthcare-seeking behavior and non-adherence. Conclusions This study identified actionable barriers to ACS care in northern Tanzania. Multifaceted interventions are urgently needed to improve care.
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Affiliation(s)
- Julian T Hertz
- Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Durham, NC, USA
| | - Godfrey L Kweka
- Kilimanjaro Christian Research Institute, PO Box 3010, Moshi, Tanzania
| | - Preeti Manavalan
- Department of Medicine, Duke University, 2301 Erwin Rd, Durham, NC, USA
| | - Melissa H Watt
- Duke Global Health Institute, 310 Trent Dr, Durham, NC, USA
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
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31
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Hertz JT, Sakita FM, Limkakeng AT, Mmbaga BT, Appiah LT, Bartlett JA, Galson SW. The burden of acute coronary syndrome, heart failure, and stroke among emergency department admissions in Tanzania: A retrospective observational study. Afr J Emerg Med 2019; 9:180-184. [PMID: 31890481 PMCID: PMC6933214 DOI: 10.1016/j.afjem.2019.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 04/01/2019] [Revised: 06/26/2019] [Accepted: 07/12/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction The prevalence of cardiovascular disease in sub-Saharan Africa is substantial and growing. Much remains to be learned about the relative burden of acute coronary syndrome (ACS), heart failure, and stroke on emergency departments and hospital admissions. Methods A retrospective chart review of admissions from September 2017 through March 2018 was conducted at the emergency department of a tertiary care center in northern Tanzania. Stroke admission volume was compared to previously published data from the same hospital and adjusted for population growth. Results Of 2418 adult admissions, heart failure and stroke were the two most common admission diagnoses, accounting for 294 (12.2%) and 204 (8.4%) admissions, respectively. ACS was uncommon, accounting for 9 (0.3%) admissions. Of patients admitted for heart failure, uncontrolled hypertension was the most commonly identified etiology of heart failure, cited in 124 (42.2%) cases. Ischemic heart disease was cited as the etiology in only 1 (0.3%) case. Adjusting for population growth, the annual volume of stroke admissions increased 70-fold in 43 years, from 2.9 admissions per 100,000 population in 1974 to 202.2 admissions per 100,000 in 2017. Conclusions The burden of heart failure and stroke on hospital admissions in Tanzania is substantial, and the volume of stroke admissions is rising precipitously. ACS is a rare diagnosis, and the distribution of cardiovascular disease phenotypes in Tanzania differs from what has been observed outside of Africa. Further research is needed to ascertain the reasons for these differences. In northern Tanzania, acute coronary syndrome is a rare admission diagnosis Heart failure and stroke are the most common admission diagnoses The burden of stroke admissions in this community is rising rapidly
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Affiliation(s)
- Julian T. Hertz
- Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, United States of America
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, United States of America
- Corresponding author at: Duke Global Health Institute, Box 102359, Duke University, Durham, NC 27710, United States of America.
| | - Francis M. Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Alexander T. Limkakeng
- Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, United States of America
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Research Institute, Kilimanjaro Christian Medical University, PO Box 3010, Moshi, Tanzania
| | - Lambert T. Appiah
- Department of Cardiology, Komfo Anokye Teaching Hospital, PO Box 1934, Kumasi, Ghana
| | - John A. Bartlett
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, United States of America
| | - Sophie W. Galson
- Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, United States of America
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32
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Hertz JT, Sakita FM, Manavalan P, Madut DB, Thielman NM, Mmbaga BT, Staton CA, Galson SW. The Burden of Hypertension and Diabetes in an Emergency Department in Northern Tanzania. Ethn Dis 2019; 29:559-566. [PMID: 31641323 DOI: 10.18865/ed.29.4.559] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction Little is known about the burden of hypertension and diabetes on emergency department (ED) utilization and hospitalizations in sub-Saharan Africa. Methods A retrospective review of adult ED patients in northern Tanzania was performed from September 2017 through March 2018. Hypertension was defined as documented diagnosis of hypertension or blood pressure ≥ 140/90 mm Hg. Diabetes was defined as documented diagnosis of diabetes mellitus or random glucose ≥ 200 mg/dL. Results Of 3961 adult ED patients, 1359 (34.3%) had hypertension, 518 (13.1%) had diabetes, and 273 (6.9%) had both. Both hypertension (OR 1.42, 95% CI 1.23-1.63, P<.001) and diabetes (OR 2.05, 95% CI 1.66-2.54, P<.001) were associated with increased odds of admission. Of 2418 hospital admissions, 694 (28.7%) were for complications of hypertension or diabetes. Of 499 patients admitted for hypertensive complications, the most common admission diagnoses were: heart failure (163 patients, 32.7%); stroke (147 patients, 29.5%); and severe hypertension (139 patients, 27.9%). Of 278 patients admitted for diabetic complications, the most common admission diagnoses were: hyperglycemia (158 patients, 56.9%); infection (60 patients, 21.6%); and stroke (28 patients, 10.1%). Conclusions The burden of hypertension and diabetes in a Tanzanian ED is high, and the ED may serve as an opportune location for case identification and linkage-to-care interventions. Given the large proportion of Africans with undiagnosed hypertension and diabetes, an ED-based screening program would likely identify many new cases of these diseases. The high burden of hypertension- and diabetes-related hospitalizations highlights the urgent need for improvements in primary preventative care in Tanzania.
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Affiliation(s)
- Julian T Hertz
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC.,Duke Global Health Institute, Duke University, Durham, NC
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Deng B Madut
- Department of Medicine, Duke University, Durham, NC
| | | | - Blandina T Mmbaga
- Kilimanjaro Christian Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Catherine A Staton
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC.,Duke Global Health Institute, Duke University, Durham, NC
| | - Sophie W Galson
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC
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33
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Hertz JT, Sakita FM, Manavalan P, Mmbaga BT, Thielman NM, Staton CA. Knowledge, attitudes, and preventative practices regarding ischemic heart disease among emergency department patients in northern Tanzania. Public Health 2019; 175:60-67. [PMID: 31401252 DOI: 10.1016/j.puhe.2019.06.017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/11/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The objective of this study is to increase understanding of knowledge, attitudes, and preventative practices regarding ischemic heart disease (IHD) in sub-Saharan Africa in order to develop patient-centered interventions to improve care and outcomes. STUDY DESIGN This is a prospective observational study. METHODS Adult patients presenting with chest pain or shortness of breath to an emergency department in northern Tanzania were enrolled. A questionnaire was adapted from existing knowledge attitude and practice surveys regarding cardiovascular disease and the WHO STEPS instrument. Individual five-year risk of cardiovascular event was determined by validated models based on age, sex, systolic blood pressure, body mass index, diabetes, and smoking status. An IHD knowledge score was calculated by giving one point for each correct response to the knowledge-related items, with a maximum score of 10. Associations between IHD knowledge and patient characteristics were assessed by Welch's t-test. RESULTS A total of 349 patients were enrolled, with median interquartile range (IQR) age 60 (45, 72) years. Of participants, 259 (74.2%) had hypertension, and 228 (65.3%) had greater than 10% five-year risk of cardiovascular event. The mean (SD) knowledge score was 4.8 (3.3). The majority of respondents (224, 64.2%) recognized obesity as a risk factor for heart attack, while a minority (34, 9.7%) knew that a daily aspirin could reduce the risk of cardiovascular event. Greater IHD knowledge was associated with younger age (P = 0.045) and higher levels of education (P < 0.001) but not higher risk of cardiovascular disease (P = 0.123). Most respondents expressed a willingness to diet to improve their health (322, 92.3%) and a preference for treatment from a physician rather than a traditional healer for a heart attack (321, 92.0%). A minority of patients reported exercising regularly (88, 25.2%) or seeing a doctor routinely for checkups (100, 28.7%). CONCLUSIONS High-risk emergency department patients in northern Tanzania have moderate knowledge regarding IHD but do not consistently engage in healthy preventive practices. Patient-centered interventions are needed to improve IHD knowledge and practices in high-risk populations.
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Affiliation(s)
- J T Hertz
- Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA; Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC 27710, USA.
| | - F M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - P Manavalan
- Department of Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - B T Mmbaga
- Kilimanjaro Christian Research Institute, Tumaini University, PO Box 3010, Moshi, Tanzania
| | - N M Thielman
- Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC 27710, USA
| | - C A Staton
- Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA; Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC 27710, USA
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Carugati M, Biggs HM, Maze MJ, Stoddard RA, Cash-Goldwasser S, Hertz JT, Halliday JEB, Saganda W, Lwezaula BF, Kazwala RR, Cleaveland S, Maro VP, Rubach MP, Crump JA. Incidence of human brucellosis in the Kilimanjaro Region of Tanzania in the periods 2007-2008 and 2012-2014. Trans R Soc Trop Med Hyg 2019; 112:136-143. [PMID: 29697848 PMCID: PMC5961162 DOI: 10.1093/trstmh/try033] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/23/2018] [Indexed: 11/23/2022] Open
Abstract
Background Brucellosis causes substantial morbidity among humans and their livestock. There are few robust estimates of the incidence of brucellosis in sub-Saharan Africa. Using cases identified through sentinel hospital surveillance and health care utilization data, we estimated the incidence of brucellosis in Moshi Urban and Moshi Rural Districts, Kilimanjaro Region, Tanzania, for the periods 2007–2008 and 2012–2014. Methods Cases were identified among febrile patients at two sentinel hospitals and were defined as having either a 4-fold increase in Brucella microscopic agglutination test titres between acute and convalescent serum or a blood culture positive for Brucella spp. Findings from a health care utilization survey were used to estimate multipliers to account for cases not seen at sentinel hospitals. Results Of 585 patients enrolled in the period 2007–2008, 13 (2.2%) had brucellosis. Among 1095 patients enrolled in the period 2012–2014, 32 (2.9%) had brucellosis. We estimated an incidence (range based on sensitivity analysis) of brucellosis of 35 (range 32–93) cases per 100 000 persons annually in the period 2007–2008 and 33 (range 30–89) cases per 100 000 persons annually in the period 2012–2014. Conclusions We found a moderate incidence of brucellosis in northern Tanzania, suggesting that the disease is endemic and an important human health problem in this area.
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Affiliation(s)
- Manuela Carugati
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Division of Infectious Diseases, San Gerardo Hospital, Monza, Italy
| | - Holly M Biggs
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Michael J Maze
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Robyn A Stoddard
- Centers for Disease Control and Prevention, Bacterial Special Pathogens Branch, Atlanta, GA, USA
| | - Shama Cash-Goldwasser
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jo E B Halliday
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | | | | | | | - Sarah Cleaveland
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Venance P Maro
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Matthew P Rubach
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - John A Crump
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA.,Centre for International Health, University of Otago, Dunedin, New Zealand.,Duke Global Health Institute, Duke University, Durham, NC, USA.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Hertz JT, Madut DB, William G, Maro VP, Crump JA, Rubach MP. Perceptions of Stroke and Associated Health-Care-Seeking Behavior in Northern Tanzania: A Community-Based Study. Neuroepidemiology 2019; 53:41-47. [PMID: 30986785 PMCID: PMC6842572 DOI: 10.1159/000499069] [Citation(s) in RCA: 4] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/22/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Little is known about knowledge of stroke symptoms, perceptions of self-risk, and health-care-seeking behavior for stroke in East Africa. METHODS A 2-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified household health-care decision makers were asked to list all symptoms of a stroke. They were further asked if they thought they had a chance of having a stroke and where they would present for care for stroke-like symptoms. A socioeconomic status score was derived via principal component analysis from 9 variables related to wealth. RESULTS Of 670 respondents, 184 (27.4%) knew a conventional stroke symptom and 51 (7.6%) thought they had a chance of having a stroke. Females were less likely to perceive themselves to be at risk than males (OR 0.49, 95% CI 0.28-0.89, p = 0.014). Of respondents, 558 (88.3%) stated they would present to a hospital for stroke-like symptoms. Preference for a hospital was not associated with knowledge of stroke symptoms or perception of self-risk but was associated with a higher socioeconomic status score (p < 0.001). CONCLUSIONS Knowledge of stroke symptoms and perception of self-risk are low in northern Tanzania, but most residents would present to a hospital for stroke-like symptoms.
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Affiliation(s)
- Julian T Hertz
- Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA,
| | - Deng B Madut
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Venance P Maro
- Department of Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - John A Crump
- Otago Global Health Institute, University of Otago, Dunedin, New Zealand
| | - Matthew P Rubach
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Hertz JT, Madut DB, Tesha RA, William G, Simmons RA, Galson SW, Sakita FM, Maro VP, Bloomfield GS, Crump JA, Rubach MP. Knowledge of myocardial infarction symptoms and perceptions of self-risk in Tanzania. Am Heart J 2019; 210:69-74. [PMID: 30743209 PMCID: PMC6453561 DOI: 10.1016/j.ahj.2019.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/09/2019] [Indexed: 11/19/2022]
Abstract
Background Little is known about community knowledge of myocardial infarction symptoms and perceptions of self-risk in sub-Saharan Africa. Methods A community survey was conducted in northern Tanzania, where the prevalence of cardiovascular risk factors is high. Households were selected randomly in a population-weighted fashion and surveys were administered to self-identified household healthcare decision-makers. Respondents were asked to list all symptoms of a heart attack and asked whether they thought they had a chance of suffering a heart attack. Associations between participant sociodemographic features and responses to these questions were assessed with Pearson's chi-squared and the Student t test. Results There were 718 survey participants, with median (IQR) age 48 (32, 62) years. Of these, 115 (16.0%) were able to identify any conventional symptom of a heart attack, including 24 (3.3%) respondents who cited chest pain as a possible symptom. There was no association between ability to identify a conventional symptom and gender, level of education, socioeconomic status, urban residence, or age. Of respondents, 198 (27.6%) thought they had a chance of suffering a heart attack. Older respondents were more likely to perceive themselves to be at risk (P < .001), but there was no association between perception of self-risk and gender, level of education, socioeconomic status, or urban residence. Conclusions In northern Tanzania, knowledge of myocardial infarction symptoms is poor among all segments of the population and only a minority of residents perceive themselves to be at risk of this disease. Educational interventions regarding ischemic heart disease are urgently needed.
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Affiliation(s)
- Julian T Hertz
- Division of Emergency Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC.
| | - Deng B Madut
- Department of Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC
| | - Revogatus A Tesha
- Department of Statistical Science, Duke University, PO Box 90251, Durham, NC
| | - Gwamaka William
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Ryan A Simmons
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC
| | - Sophie W Galson
- Division of Emergency Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Venance P Maro
- Department of Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Gerald S Bloomfield
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC
| | - John A Crump
- Otago Global Health Institute, University of Otago, PO Box 56, Dunedin, New Zealand 9054
| | - Matthew P Rubach
- Department of Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC
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Hertz JT, Madut DB, Tesha RA, William G, Simmons RA, Galson SW, Sakita FM, Maro VP, Bloomfield GS, Crump JA, Rubach MP. Perceptions of chest pain and healthcare seeking behavior for chest pain in northern Tanzania: A community-based survey. PLoS One 2019; 14:e0212139. [PMID: 30753216 PMCID: PMC6372176 DOI: 10.1371/journal.pone.0212139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 12/10/2018] [Accepted: 01/28/2019] [Indexed: 12/17/2022] Open
Abstract
Background Little is known about community perceptions of chest pain and healthcare seeking behavior for chest pain in sub-Saharan Africa. Methods A two-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified household healthcare decision-makers from randomly selected households were asked to list all possible causes of chest pain in an adult and asked where they would go if an adult household member had chest pain. Results Of 718 respondents, 485 (67.5%) were females. The most commonly cited causes of chest pain were weather and exercise, identified by 342 (47.6%) and 318 (44.3%) respondents. Two (0.3%) respondents identified ‘heart attack’ as a possible cause of chest pain. A hospital was selected as the preferred healthcare facility for an adult with chest pain by 277 (38.6%) respondents. Females were less likely to prefer a hospital than males (OR 0.65, 95% CI 0.47–0.90, p = 0.008). Conclusions There is little community awareness of cardiac causes of chest pain in northern Tanzania, and most adults reported that they would not present to a hospital for this symptom. There is an urgent need for educational interventions to address this knowledge deficit and guide appropriate care-seeking behavior.
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Affiliation(s)
- Julian T. Hertz
- Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- * E-mail:
| | - Deng B. Madut
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Revogatus A. Tesha
- Department of Statistical Science, Duke University, Durham, North Carolina, United States of America
| | | | - Ryan A. Simmons
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Sophie W. Galson
- Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Francis M. Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Venance P. Maro
- Department of Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Gerald S. Bloomfield
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - John A. Crump
- Otago Global Health Institute, University of Otago, Dunedin, New Zealand
| | - Matthew P. Rubach
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
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Galson SW, Stanifer JW, Hertz JT, Temu G, Thielman N, Gafaar T, Staton CA. The burden of hypertension in the emergency department and linkage to care: A prospective cohort study in Tanzania. PLoS One 2019; 14:e0211287. [PMID: 30682173 PMCID: PMC6347227 DOI: 10.1371/journal.pone.0211287] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/10/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Globally, hypertension affects one billion people and disproportionately burdens low-and middle-income countries. Despite the high disease burden in sub-Saharan Africa, optimal care models for diagnosing and treating hypertension have not been established. Emergency departments (EDs) are frequently the first biomedical healthcare contact for many people in the region. ED encounters may offer a unique opportunity for identifying high risk patients and linking them to care. METHODS Between July 2017 and March 2018, we conducted a prospective cohort study among patients presenting to a tertiary care ED in northern Tanzania. We recruited adult patients with a triage blood pressure ≥ 140/90 mmHg in order to screen for hypertension. We explored knowledge, attitudes and practices for hypertension using a questionnaire, and assessed factors associated with successful follow-up. Hypertension was defined as a single blood pressure measurement ≥ 160/100 mmHg or a three-time average of ≥ 140/90 mmHg. Uncontrolled hypertension was defined as a three-time average measurement of ≥ 160/100 mmHg. Successful follow-up was defined as seeing an outpatient provider within one month of the ED visit. RESULTS We enrolled 598 adults (mean age 59.6 years), of whom 539 (90.1%) completed the study. The majority (78.6%) of participants were aware of having hypertension. Many (223; 37.2%) had uncontrolled hypertension. Overall, only 236 (43.8%) of participants successfully followed-up within one month. Successful follow-up was associated with a greater understanding that hypertension requires lifelong treatment (RR 1.11; 95% CI 1.03,1.21) and inversely associated with greater anxiety about the future (RR 0.80; 95% CI 0.64,0.99). CONCLUSION In a northern Tanzanian tertiary care ED, the burden of hypertension is high, with few patients receiving optimal outpatient care follow-up. Multi-disciplinary strategies are needed to improve linkage to care for high-risk patients from ED settings.
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Affiliation(s)
- Sophie W. Galson
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
| | - John W. Stanifer
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Division of Nephrology, Duke University, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Gloria Temu
- Department of Medicine, Kilimanjaro Christian Medical College Hospital, Kilimanjaro, Tanzania
| | - Nathan Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Temitope Gafaar
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Catherine A. Staton
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Neurosurgery, Division of Global Neurosurgery and Neuroscience, Durham, North Carolina, United States of America
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Hertz JT, Fu T, Vissoci JR, Rocha TAH, Carvalho E, Flanagan B, de Andrade L, Limkakeng AT, Staton CA. The distribution of cardiac diagnostic testing for acute coronary syndrome in the Brazilian healthcare system: A national geospatial evaluation of health access. PLoS One 2019; 14:e0210502. [PMID: 30629670 PMCID: PMC6328143 DOI: 10.1371/journal.pone.0210502] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/24/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about the utilization of cardiac diagnostic testing in Brazil and how such testing is related with local rates of acute coronary syndrome (ACS)-related mortality. METHODS AND RESULTS Using data from DATASUS, the public national healthcare database, absolute counts of diagnostic tests performed were calculated for each of the 5570 municipalities and mapped. Spatial error regression and geographic weighted regression models were used to describe the geographic variation in the association between ACS mortality, income, and access to diagnostic testing. From 2008 to 2014, a total of 4,653,884 cardiac diagnostic procedures were performed in Brazil, at a total cost of $271 million USD. The overall ACS mortality rate during this time period was 133.8 deaths per 100,000 inhabitants aged 20 to 79. The most commonly utilized test was the stress ECG (3,015,993), followed by catheterization (862,627), scintigraphy (669,969) and stress echocardiography (105,295). The majority of these procedures were conducted in large urban centers in more economically developed regions of the country. Increased access to testing and increased income were not uniformly associated with decreased ACS mortality, and tremendous geographic heterogeneity was observed in the relationship between these variables. CONCLUSIONS The majority of testing for ACS in Brazil is conducted at referral centers in developed urban settings. Stress ECG is the dominant testing modality in use. Increased access to diagnostic testing was not consistently associated with decreased ACS mortality across the country.
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Affiliation(s)
- Julian T. Hertz
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Tommy Fu
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joao Ricardo Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Centro Universitario Inga, Maringa, Brazil
| | | | - Elias Carvalho
- Department of Computer Science, Pontifical University Catholic of Parana, Curitiba, Brazil
- Data Processing Department, State University of Maringa, Maringa, Brazil
| | - Brendan Flanagan
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Alex T. Limkakeng
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Catherine A. Staton
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
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Abstract
INTRODUCTION Sub-Saharan Africa is particularly vulnerable to the growing global burden of hypertension, but epidemiological studies are limited and barriers to optimal management are poorly understood. Therefore, we undertook a community-based mixed-methods study in Tanzania to investigate the epidemiology of hypertension and barriers to care. METHODS In Northern Tanzania, between December 2013 and June 2015, we conducted a mixed-methods study, including a cross-sectional household epidemiological survey and qualitative sessions of focus groups and in-depth interviews. For the survey, we assessed for hypertension, defined as a single blood pressure ≥160/100 mm Hg, a two-time average of ≥140/90 mm Hg or current use of antihypertensive medications. To investigate relationships with potential risk factors, we used adjusted generalised linear models. Uncontrolled hypertension was defined as a two-time average measurement of ≥160/100 mm Hg irrespective of treatment status. Hypertension awareness was defined as a self-reported disease history in a participant with confirmed hypertension. To explore barriers to care, we identified emerging themes using an inductive approach within the framework method. RESULTS We enrolled 481 adults (median age 45 years) from 346 households, including 123 men (25.6%) and 358 women (74.4%). Overall, the prevalence of hypertension was 28.0% (95% CI 19.4% to 38.7%), which was independently associated with age >60 years (prevalence risk ratio (PRR) 4.68; 95% CI 2.25 to 9.74) and alcohol use (PRR 1.72; 95% CI 1.15 to 2.58). Traditional medicine use was inversely associated with hypertension (PRR 0.37; 95% CI 0.26 to 0.54). Nearly half (48.3%) of the participants were aware of their disease, but almost all (95.3%) had uncontrolled hypertension. In the qualitative sessions, we identified barriers to optimal care, including poor point-of-care communication, poor understanding of hypertension and structural barriers such as long wait times and undertrained providers. CONCLUSIONS In Northern Tanzania, the burden of hypertensive disease is substantial, and optimal hypertension control is rare. Transdisciplinary strategies sensitive to local practices should be explored to facilitate early diagnosis and sustained care delivery.
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Affiliation(s)
- Sophie W Galson
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - Catherine A Staton
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
- Division of Global Neurosurgery and Neuroscience, Department of Neurosurgery, Duke Global Health Institute, Durham, North Carolina, USA
| | - Francis Karia
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Kajiru Kilonzo
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Joseph Lunyera
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Uptal D Patel
- Department of Medicine, Duke Clinical Research Institute , Duke University, Durham, North Carolina, USA
| | - Julian T Hertz
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - John W Stanifer
- Duke Global Health Institute, Durham, North Carolina, USA
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, USA
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Abstract
Little is known about the presence and distribution of Aedes mosquitoes in northern Tanzania despite the occurence of viruses transmitted by these mosquitoes such as Chikungunya virus (CHIKV) and Dengue virus (DENV) in the region. Adult and larval mosquitoes were collected from rural and urban settings across a wide range of altitudes in the Kilimanjaro Region using the Mosquito Magnet CO2 Trap for collection of adults and old tires for breeding of larvae. Polymerase chain reaction assays were performed on captured adult mosquitoes to detect the presence of CHIKV and DENV. A total of 2609 Aedes aegypti adult mosquitoes were collected; no other Aedes species larvae were found. Mosquito yields were significantly higher in urban settings than rural settings (26.5 vs. 1.9 mosquitoes per day, p = 0.037). A total of 6570 Ae. aegypti larvae were collected from old tires; no other Aedes species larvae were found. Of the 2609 adult mosquitoes collected, none tested positive for CHIKV or DENV. As far as we are aware, this paper reports for the first time the presence of Ae. aegypti in the Kilimanjaro Region of northern Tanzania. Although CHIKV and DENV were not isolated from any of the collected mosquitoes in this study, the apparent absence of other Aedes species in the area suggests that Ae. aegypti is the primary local vector of these infections.
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Affiliation(s)
- Julian T Hertz
- a Department of Medicine, Division of Infectious Diseases and International Health , Duke University Medical Center , Durham , NC , USA
| | | | - Eng Eong Ooi
- c Emerging Infectious Diseases Signature Research Program , Duke-National University of Singapore Graduate Medical School , Singapore
| | - Franklin W Mosha
- d Kilimanjaro Christian Medical University College, Tumaini University , Moshi , Tanzania
| | - John A Crump
- a Department of Medicine, Division of Infectious Diseases and International Health , Duke University Medical Center , Durham , NC , USA.,d Kilimanjaro Christian Medical University College, Tumaini University , Moshi , Tanzania.,e Kilimanjaro Christian Medical Centre , Moshi , Tanzania.,f Duke Global Health Institute, Duke University , Durham , NC, USA.,g Centre for International Health, University of Otago , Dunedin , New Zealand
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Marks F, von Kalckreuth V, Aaby P, Adu-Sarkodie Y, El Tayeb MA, Ali M, Aseffa A, Baker S, Biggs HM, Bjerregaard-Andersen M, Breiman RF, Campbell JI, Cosmas L, Crump JA, Espinoza LMC, Deerin JF, Dekker DM, Fields BS, Gasmelseed N, Hertz JT, Van Minh Hoang N, Im J, Jaeger A, Jeon HJ, Kabore LP, Keddy KH, Konings F, Krumkamp R, Ley B, Løfberg SV, May J, Meyer CG, Mintz ED, Montgomery JM, Niang AA, Nichols C, Olack B, Pak GD, Panzner U, Park JK, Park SE, Rabezanahary H, Rakotozandrindrainy R, Raminosoa TM, Razafindrabe TJL, Sampo E, Schütt-Gerowitt H, Sow AG, Sarpong N, Seo HJ, Sooka A, Soura AB, Tall A, Teferi M, Thriemer K, Warren MR, Yeshitela B, Clemens JD, Wierzba TF. Incidence of invasive salmonella disease in sub-Saharan Africa: a multicentre population-based surveillance study. Lancet Glob Health 2017; 5:e310-e323. [PMID: 28193398 PMCID: PMC5316558 DOI: 10.1016/s2214-109x(17)30022-0] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [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: 10/07/2016] [Revised: 11/17/2016] [Accepted: 11/23/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Available incidence data for invasive salmonella disease in sub-Saharan Africa are scarce. Standardised, multicountry data are required to better understand the nature and burden of disease in Africa. We aimed to measure the adjusted incidence estimates of typhoid fever and invasive non-typhoidal salmonella (iNTS) disease in sub-Saharan Africa, and the antimicrobial susceptibility profiles of the causative agents. METHODS We established a systematic, standardised surveillance of blood culture-based febrile illness in 13 African sentinel sites with previous reports of typhoid fever: Burkina Faso (two sites), Ethiopia, Ghana, Guinea-Bissau, Kenya, Madagascar (two sites), Senegal, South Africa, Sudan, and Tanzania (two sites). We used census data and health-care records to define study catchment areas and populations. Eligible participants were either inpatients or outpatients who resided within the catchment area and presented with tympanic (≥38·0°C) or axillary temperature (≥37·5°C). Inpatients with a reported history of fever for 72 h or longer were excluded. We also implemented a health-care utilisation survey in a sample of households randomly selected from each study area to investigate health-seeking behaviour in cases of self-reported fever lasting less than 3 days. Typhoid fever and iNTS disease incidences were corrected for health-care-seeking behaviour and recruitment. FINDINGS Between March 1, 2010, and Jan 31, 2014, 135 Salmonella enterica serotype Typhi (S Typhi) and 94 iNTS isolates were cultured from the blood of 13 431 febrile patients. Salmonella spp accounted for 33% or more of all bacterial pathogens at nine sites. The adjusted incidence rate (AIR) of S Typhi per 100 000 person-years of observation ranged from 0 (95% CI 0-0) in Sudan to 383 (274-535) at one site in Burkina Faso; the AIR of iNTS ranged from 0 in Sudan, Ethiopia, Madagascar (Isotry site), and South Africa to 237 (178-316) at the second site in Burkina Faso. The AIR of iNTS and typhoid fever in individuals younger than 15 years old was typically higher than in those aged 15 years or older. Multidrug-resistant S Typhi was isolated in Ghana, Kenya, and Tanzania (both sites combined), and multidrug-resistant iNTS was isolated in Burkina Faso (both sites combined), Ghana, Kenya, and Guinea-Bissau. INTERPRETATION Typhoid fever and iNTS disease are major causes of invasive bacterial febrile illness in the sampled locations, most commonly affecting children in both low and high population density settings. The development of iNTS vaccines and the introduction of S Typhi conjugate vaccines should be considered for high-incidence settings, such as those identified in this study. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Florian Marks
- International Vaccine Institute, SNU Research Park, Seoul, South Korea.
| | | | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Yaw Adu-Sarkodie
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Mohammad Ali
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Holly M Biggs
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, NC, USA
| | - Morten Bjerregaard-Andersen
- Bandim Health Project, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Robert F Breiman
- Centers for Disease Control and Prevention, Nairobi, Kenya; Global Health Institute, Emory University, Atlanta, GA, USA
| | - James I Campbell
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Leonard Cosmas
- Centers for Disease Control and Prevention, Nairobi, Kenya; WHO-Kenya Country Office, Nairobi, Kenya
| | - John A Crump
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, NC, USA; Duke Global Health Institute, Duke University, Durham, NC, USA; Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | | | - Denise Myriam Dekker
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany; German Center for Infection Research, Hamburg-Borstel-Lübeck, Germany
| | - Barry S Fields
- Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Nagla Gasmelseed
- Faculty of Medicine, University of Gezira, Wad Medani, Sudan; Faculty of Science, University of Hafr Al Batin, Hafr Al Batin, Saudi Arabia
| | - Julian T Hertz
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, NC, USA
| | | | - Justin Im
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | - Anna Jaeger
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Hyon Jin Jeon
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | | | - Karen H Keddy
- National Institute for Communicable Diseases, Johannesburg, South Africa; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frank Konings
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | - Ralf Krumkamp
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany; German Center for Infection Research, Hamburg-Borstel-Lübeck, Germany
| | - Benedikt Ley
- International Vaccine Institute, SNU Research Park, Seoul, South Korea; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia
| | - Sandra Valborg Løfberg
- Bandim Health Project, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Jürgen May
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany; German Center for Infection Research, Hamburg-Borstel-Lübeck, Germany
| | - Christian G Meyer
- Institute of Tropical Medicine, Eberhard-Karls University Tübingen, Tübingen, Germany; Duy Tan University, Da Nang, Vietnam
| | - Eric D Mintz
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Chelsea Nichols
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | - Beatrice Olack
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Gi Deok Pak
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | - Ursula Panzner
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | - Jin Kyung Park
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | - Se Eun Park
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | | | | | | | | | | | - Heidi Schütt-Gerowitt
- International Vaccine Institute, SNU Research Park, Seoul, South Korea; Institute of Medical Microbiology, University of Cologne, Cologne, Germany
| | - Amy Gassama Sow
- Institute Pasteur de Dakar, Dakar, Senegal; University Cheikh Anta Diop de Dakar, Dakar, Senegal
| | - Nimako Sarpong
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; German Center for Infection Research, Hamburg-Borstel-Lübeck, Germany
| | - Hye Jin Seo
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | - Arvinda Sooka
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Abdramane Bassiahi Soura
- Institut Supérieur des Sciences de la Population, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Adama Tall
- Institute Pasteur de Dakar, Dakar, Senegal
| | | | - Kamala Thriemer
- International Vaccine Institute, SNU Research Park, Seoul, South Korea; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia
| | - Michelle R Warren
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
| | | | - John D Clemens
- International Vaccine Institute, SNU Research Park, Seoul, South Korea; International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh; University of California Fielding School of Public Health, Los Angeles, CA, USA
| | - Thomas F Wierzba
- International Vaccine Institute, SNU Research Park, Seoul, South Korea
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Al-Emran HM, Krumkamp R, Dekker DM, Eibach D, Aaby P, Adu-Sarkodie Y, Ali M, Rubach MP, Bjerregaard-Andersen M, Crump JA, Cruz Espinoza LM, Løfberg SV, Gassama Sow A, Hertz JT, Im J, Jaeger A, Kabore LP, Konings F, Meyer CG, Niang A, Pak GD, Panzner U, Park SE, Rabezanahary H, Rakotozandrindrainy R, Raminosoa TM, Razafindrabe TJL, Sampo E, Schütt-Gerowitt H, Sarpong N, Soura AB, Tall A, von Kalckreuth V, Wierzba TF, May J, Marks F. Validation and Identification of Invasive Salmonella Serotypes in Sub-Saharan Africa by Multiplex Polymerase Chain Reaction. Clin Infect Dis 2016; 62 Suppl 1:S80-2. [PMID: 26933026 DOI: 10.1093/cid/civ782] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 01/19/2023] Open
Abstract
Salmonella enterica serovar Typhi and nontyphoidal Salmonella (NTS) cause the majority of bloodstream infections in sub-Saharan Africa; however, serotyping is rarely performed. We validated a multiplex polymerase chain reaction (PCR) assay with the White-Kauffmann-Le Minor (WKLM) scheme of serotyping using 110 Salmonella isolates from blood cultures of febrile children in Ghana and applied the method in other Typhoid Fever Surveillance in Africa Program study sites. In Ghana, 47 (43%) S. Typhi, 36 (33%) Salmonella enterica serovar Typhimurium, 14 (13%) Salmonella enterica serovar Dublin, and 13 (12%) Salmonella enterica serovar Enteritidis were identified by both multiplex PCR and the WKLM scheme separately. Using the validated multiplex PCR assay, we identified 42 (66%) S. Typhi, 14 (22%) S. Typhimurium, 2 (3%) S. Dublin, 2 (3%) S. Enteritidis, and 4 (6%) other Salmonella species from the febrile patients in Burkina Faso, Guinea-Bissau, Madagascar, Senegal, and Tanzania. Application of this multiplex PCR assay in sub-Saharan Africa could advance the knowledge of serotype distribution of Salmonella.
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Affiliation(s)
| | - Ralf Krumkamp
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | | | - Daniel Eibach
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Yaw Adu-Sarkodie
- Kwame Nkrumah University of Science and Technology Kumasi Centre for Collaborative Research in Tropical Medicine, Ghana
| | - Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mathew P Rubach
- Division of Infectious Diseases and International Health, Duke University Medical Center
| | | | - John A Crump
- Division of Infectious Diseases and International Health, Duke University Medical Center Duke Global Health Institute, Duke University, Durham, North Carolina Kilimanjaro Christian Medical Centre, Moshi, Tanzania Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | - Sandra Valborg Løfberg
- Bandim Health Project, Bissau, Guinea-Bissau Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Amy Gassama Sow
- Institute Pasteur Senegal Université Cheikh Anta Diop de Dakar, Senegal
| | - Julian T Hertz
- Division of Infectious Diseases and International Health, Duke University Medical Center Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Justin Im
- International Vaccine Institute, Seoul, Republic of Korea
| | - Anna Jaeger
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | | | - Frank Konings
- International Vaccine Institute, Seoul, Republic of Korea
| | - Christian G Meyer
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany Institute of Tropical Medicine, Eberhard-Karls University Tübingen, Germany
| | | | - Gi Deok Pak
- International Vaccine Institute, Seoul, Republic of Korea
| | - Ursula Panzner
- International Vaccine Institute, Seoul, Republic of Korea
| | - Se Eun Park
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | | | | | - Emmanuel Sampo
- Institut Supérieur des Sciences de la Population, University of Ouagadougou, Burkina Faso
| | - Heidi Schütt-Gerowitt
- International Vaccine Institute, Seoul, Republic of Korea Institute of Medical Microbiology, University of Cologne, Germany
| | - Nimako Sarpong
- Kumasi Centre for Collaborative Research in Tropical Medicine, Ghana
| | | | | | | | | | - Jürgen May
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
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Park SE, Pak GD, Aaby P, Adu-Sarkodie Y, Ali M, Aseffa A, Biggs HM, Bjerregaard-Andersen M, Breiman RF, Crump JA, Cruz Espinoza LM, Eltayeb MA, Gasmelseed N, Hertz JT, Im J, Jaeger A, Parfait Kabore L, von Kalckreuth V, Keddy KH, Konings F, Krumkamp R, MacLennan CA, Meyer CG, Montgomery JM, Ahmet Niang A, Nichols C, Olack B, Panzner U, Park JK, Rabezanahary H, Rakotozandrindrainy R, Sampo E, Sarpong N, Schütt-Gerowitt H, Sooka A, Soura AB, Sow AG, Tall A, Teferi M, Yeshitela B, May J, Wierzba TF, Clemens JD, Baker S, Marks F. The Relationship Between Invasive Nontyphoidal Salmonella Disease, Other Bacterial Bloodstream Infections, and Malaria in Sub-Saharan Africa. Clin Infect Dis 2016; 62 Suppl 1:S23-31. [PMID: 26933016 DOI: 10.1093/cid/civ893] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [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: 01/31/2023] Open
Abstract
BACKGROUND Country-specific studies in Africa have indicated that Plasmodium falciparum is associated with invasive nontyphoidal Salmonella (iNTS) disease. We conducted a multicenter study in 13 sites in Burkina Faso, Ethiopia, Ghana, Guinea-Bissau, Kenya, Madagascar, Senegal, South Africa, Sudan, and Tanzania to investigate the relationship between the occurrence of iNTS disease, other systemic bacterial infections, and malaria. METHODS Febrile patients received a blood culture and a malaria test. Isolated bacteria underwent antimicrobial susceptibility testing, and the association between iNTS disease and malaria was assessed. RESULTS A positive correlation between frequency proportions of malaria and iNTS was observed (P = .01; r = 0.70). Areas with higher burden of malaria exhibited higher odds of iNTS disease compared to other bacterial infections (odds ratio [OR], 4.89; 95% CI, 1.61-14.90; P = .005) than areas with lower malaria burden. Malaria parasite positivity was associated with iNTS disease (OR, 2.44; P = .031) and gram-positive bacteremias, particularly Staphylococcus aureus, exhibited a high proportion of coinfection with Plasmodium malaria. Salmonella Typhimurium and Salmonella Enteritidis were the predominant NTS serovars (53/73; 73%). Both moderate (OR, 6.05; P = .0001) and severe (OR, 14.62; P < .0001) anemia were associated with iNTS disease. CONCLUSIONS A positive correlation between iNTS disease and malaria endemicity, and the association between Plasmodium parasite positivity and iNTS disease across sub-Saharan Africa, indicates the necessity to consider iNTS as a major cause of febrile illness in malaria-holoendemic areas. Prevention of iNTS disease through iNTS vaccines for areas of high malaria endemicity, targeting high-risk groups for Plasmodium parasitic infection, should be considered.
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Affiliation(s)
- Se Eun Park
- International Vaccine Institute, Seoul, Republic of Korea
| | - Gi Deok Pak
- International Vaccine Institute, Seoul, Republic of Korea
| | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Yaw Adu-Sarkodie
- Kumasi Centre for Collaborative Research in Tropical Medicine School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea Johns Hopkins University, Baltimore, Maryland
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Holly M Biggs
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Robert F Breiman
- Centers for Disease Control and Prevention, Nairobi, Kenya Emory Global Health Institute, Emory University, Atlanta, Georgia
| | - John A Crump
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina Kilimanjaro Christian Medical Centre, Moshi, Tanzania Duke Global Health Institute, Duke University, Durham, North Carolina Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | | | | | - Julian T Hertz
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Justin Im
- International Vaccine Institute, Seoul, Republic of Korea
| | - Anna Jaeger
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | | | | | - Karen H Keddy
- National Institute for Communicable Diseases Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frank Konings
- International Vaccine Institute, Seoul, Republic of Korea
| | - Ralf Krumkamp
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Calman A MacLennan
- Jenner Institute, Nuffield Department of Medicine, University of Oxford Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, United Kingdom
| | - Christian G Meyer
- Institute of Tropical Medicine, Eberhard-Karls University Tübingen, Germany
| | | | | | | | | | - Ursula Panzner
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jin Kyung Park
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | - Emmanuel Sampo
- Schiphra Hospital, Ouagadougou, Burkina Faso Institut Supérieur des Sciences de la Population, University of Ouagadougou, Burkina Faso
| | - Nimako Sarpong
- Kumasi Centre for Collaborative Research in Tropical Medicine
| | - Heidi Schütt-Gerowitt
- International Vaccine Institute, Seoul, Republic of Korea Institute of Medical Microbiology, University of Cologne, Germany
| | | | | | - Amy Gassama Sow
- Institute Pasteur Senegal, Dakar Université Cheikh Anta Diop de Dakar, Senegal
| | | | | | | | - Jürgen May
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | | | - John D Clemens
- International Vaccine Institute, Seoul, Republic of Korea International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Fielding School of Public Health, University of California, Los Angeles
| | - Stephen Baker
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
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Maze MJ, Biggs HM, Rubach MP, Galloway RL, Cash-Goldwasser S, Allan KJ, Halliday JEB, Hertz JT, Saganda W, Lwezaula BF, Cleaveland S, Mmbaga BT, Maro VP, Crump JA. Comparison of the Estimated Incidence of Acute Leptospirosis in the Kilimanjaro Region of Tanzania between 2007-08 and 2012-14. PLoS Negl Trop Dis 2016; 10:e0005165. [PMID: 27911902 PMCID: PMC5135036 DOI: 10.1371/journal.pntd.0005165] [Citation(s) in RCA: 20] [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: 08/19/2016] [Accepted: 11/06/2016] [Indexed: 12/27/2022] Open
Abstract
Background The sole report of annual leptospirosis incidence in continental Africa of 75–102 cases per 100,000 population is from a study performed in August 2007 through September 2008 in the Kilimanjaro Region of Tanzania. To evaluate the stability of this estimate over time, we estimated the incidence of acute leptospirosis in Kilimanjaro Region, northern Tanzania for the time period 2012–2014. Methodology and Principal Findings Leptospirosis cases were identified among febrile patients at two sentinel hospitals in the Kilimanjaro Region. Leptospirosis was diagnosed by serum microscopic agglutination testing using a panel of 20 Leptospira serovars belonging to 17 separate serogroups. Serum was taken at enrolment and patients were asked to return 4–6 weeks later to provide convalescent serum. Confirmed cases required a 4-fold rise in titre and probable cases required a single titre of ≥800. Findings from a healthcare utilisation survey were used to estimate multipliers to adjust for cases not seen at sentinel hospitals. We identified 19 (1.7%) confirmed or probable cases among 1,115 patients who presented with a febrile illness. Of cases, the predominant reactive serogroups were Australis 8 (42.1%), Sejroe 3 (15.8%), Grippotyphosa 2 (10.5%), Icterohaemorrhagiae 2 (10.5%), Pyrogenes 2 (10.5%), Djasiman 1 (5.3%), Tarassovi 1 (5.3%). We estimated that the annual incidence of leptospirosis was 11–18 cases per 100,000 population. This was a significantly lower incidence than 2007–08 (p<0.001). Conclusions We estimated a much lower incidence of acute leptospirosis than previously, with a notable absence of cases due to the previously predominant serogroup Mini. Our findings indicate a dynamic epidemiology of leptospirosis in this area and highlight the value of multi-year surveillance to understand leptospirosis epidemiology. Leptospirosis is an infectious disease that causes a fever. It can be severe or fatal. Understanding how many people get leptospirosis helps to determine priorities in allocating resources for disease diagnosis, treatment, and prevention. There are few data about leptospirosis incidence in sub-Saharan African countries. The only mainland estimate is from northern Tanzania for the years 2007–08. To see if leptospirosis incidence had changed since 2007–08, we measured leptospirosis incidence in the same location in 2012–2014. To do this, we systematically approached people at two hospitals in the Kilimanjaro Region and tested them for leptospirosis. We adjusted the number of identified cases of leptospirosis found at the hospitals to account for people with fever who did not come to hospital for testing and care. We also adjusted for imperfect testing methods. We found that the number of people who developed leptospirosis annually had dropped from 75–102 cases per 100,000 people during 2007–08 to 11–18 cases per 100,000 people during 2012–14. Also, the subtype of leptospirosis responsible for the most cases during 2007–08 was not present during 2012–14. The number of people developing leptospirosis was not stable, highlighting the value of measuring how commonly leptospirosis occurs over several years.
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Affiliation(s)
- Michael J. Maze
- Centre for International Health, University of Otago, Dunedin, New Zealand
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- * E-mail:
| | - Holly M. Biggs
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Matthew P. Rubach
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Renee L. Galloway
- Centers for Disease Control and Prevention, Bacterial Special Pathogens Branch, Atlanta, Georgia, United States of America
| | - Shama Cash-Goldwasser
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Kathryn J. Allan
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Jo E. B. Halliday
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Julian T. Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | | | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Venance P. Maro
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - John A. Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Nichols C, Cruz Espinoza LM, von Kalckreuth V, Aaby P, Ahmed El Tayeb M, Ali M, Aseffa A, Bjerregaard-Andersen M, Breiman RF, Cosmas L, Crump JA, Dekker DM, Gassama Sow A, Gasmelseed N, Hertz JT, Im J, Kabore LP, Keddy KH, Konings F, Valborg Løfberg S, Meyer CG, Montgomery JM, Niang A, Njariharinjakamampionona A, Olack B, Pak GD, Panzner U, Park JK, Park SE, Rabezanahary H, Rakotondrainiarivelo JP, Rakotozandrindrainy R, Raminosoa TM, Rubach MP, Teferi M, Seo HJ, Sooka A, Soura A, Tall A, Toy T, Yeshitela B, Clemens JD, Wierzba TF, Baker S, Marks F. Bloodstream Infections and Frequency of Pretreatment Associated With Age and Hospitalization Status in Sub-Saharan Africa. Clin Infect Dis 2016; 61 Suppl 4:S372-9. [PMID: 26449954 DOI: 10.1093/cid/civ730] [Citation(s) in RCA: 16] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The clinical diagnosis of bacterial bloodstream infections (BSIs) in sub-Saharan Africa is routinely confused with malaria due to overlapping symptoms. The Typhoid Surveillance in Africa Program (TSAP) recruited febrile inpatients and outpatients of all ages using identical study procedures and enrollment criteria, thus providing an opportunity to assess disease etiology and pretreatment patterns among children and adults. METHODS Inpatients and outpatients of all ages with tympanic or axillary temperatures of ≥38.0 or ≥37.5°C, respectively, and inpatients only reporting fever within the previous 72 hours were eligible for recruitment. All recruited patients had one blood sample drawn and cultured for microorganisms. Data from 11 TSAP surveillance sites in nine different countries were used in the analysis. Bivariate analysis was used to compare frequencies of pretreatment and BSIs in febrile children (<15 years old) and adults (≥15 years old) in each country. Pooled Cochran Mantel-Haenszel odds ratios (ORs) were calculated for overall trends. RESULTS There was no significant difference in the odds of a culture-proven BSI between children and adults among inpatients or outpatients. Among both inpatients and outpatients, children had significantly higher odds of having a contaminated blood culture compared with adults. Using country-pooled data, child outpatients had 66% higher odds of having Salmonella Typhi in their bloodstream than adults (OR, 1.66; 95% confidence interval [CI], 1.01-2.73). Overall, inpatient children had 59% higher odds of pretreatment with analgesics in comparison to inpatient adults (OR, 1.59; 95% CI, 1.28-1.97). CONCLUSIONS The proportion of patients with culture-proven BSIs in children compared with adults was similar across the TSAP study population; however, outpatient children were more likely to have Salmonella Typhi infections than outpatient adults. This finding points to the importance of including outpatient facilities in surveillance efforts, particularly for the surveillance of typhoid fever. Strategies to reduce contamination among pediatric blood cultures are needed across the continent to prevent the misdiagnosis of BSI cases in children.
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Affiliation(s)
| | | | | | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | | | - Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | - Robert F Breiman
- Kenya Medical Research Institute-Center for Global Health Research, Nairobi Global Health Institute, Emory University, Atlanta, Georgia
| | - Leonard Cosmas
- Kenya Medical Research Institute-Center for Global Health Research, Nairobi Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention-Kenya, Nairobi
| | - John A Crump
- Division of Infectious Diseases and International Health, Duke University Medical Center Duke Global Health Institute, Duke University, Durham, North Carolina Centre for International Health, University of Otago, Dunedin, New Zealand Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Amy Gassama Sow
- Université Cheikh Anta Diop de Dakar Institut Pasteur de Dakar, Senegal
| | | | - Julian T Hertz
- Division of Infectious Diseases and International Health, Duke University Medical Center Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Justin Im
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Karen H Keddy
- National Institute for Communicable Diseases Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frank Konings
- International Vaccine Institute, Seoul, Republic of Korea
| | - Sandra Valborg Løfberg
- Bandim Health Project, Bissau, Guinea-Bissau Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Christian G Meyer
- Institute of Tropical Medicine, Eberhard-Karls University Tübingen, Germany
| | - Joel M Montgomery
- Kenya Medical Research Institute-Center for Global Health Research, Nairobi Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention-Kenya, Nairobi
| | | | | | - Beatrice Olack
- Kenya Medical Research Institute-Center for Global Health Research, Nairobi
| | - Gi Deok Pak
- International Vaccine Institute, Seoul, Republic of Korea
| | - Ursula Panzner
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jin Kyung Park
- International Vaccine Institute, Seoul, Republic of Korea
| | - Se Eun Park
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | | | | | - Matthew P Rubach
- Division of Infectious Diseases and International Health, Duke University Medical Center
| | | | - Hye Jin Seo
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Abdramane Soura
- Institut Supérieur des Sciences de la Population, University of Ouagadougou, Burkina Faso
| | | | - Trevor Toy
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - John D Clemens
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka UCLA Fielding School of Public Health
| | | | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
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Al-Emran HM, Eibach D, Krumkamp R, Ali M, Baker S, Biggs HM, Bjerregaard-Andersen M, Breiman RF, Clemens JD, Crump JA, Cruz Espinoza LM, Deerin J, Dekker DM, Gassama Sow A, Hertz JT, Im J, Ibrango S, von Kalckreuth V, Kabore LP, Konings F, Løfberg SV, Meyer CG, Mintz ED, Montgomery JM, Olack B, Pak GD, Panzner U, Park SE, Razafindrabe JLT, Rabezanahary H, Rakotondrainiarivelo JP, Rakotozandrindrainy R, Raminosoa TM, Schütt-Gerowitt H, Sampo E, Soura AB, Tall A, Warren M, Wierzba TF, May J, Marks F. A Multicountry Molecular Analysis of Salmonella enterica Serovar Typhi With Reduced Susceptibility to Ciprofloxacin in Sub-Saharan Africa. Clin Infect Dis 2016; 62 Suppl 1:S42-6. [PMID: 26933020 PMCID: PMC4772832 DOI: 10.1093/cid/civ788] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Salmonella enterica serovar Typhi is a predominant cause of bloodstream infections in sub-Saharan Africa (SSA). Increasing numbers of S. Typhi with resistance to ciprofloxacin have been reported from different parts of the world. However, data from SSA are limited. In this study, we aimed to measure the ciprofloxacin susceptibility of S. Typhi isolated from patients with febrile illness in SSA. METHODS Febrile patients from 9 sites within 6 countries in SSA with a body temperature of ≥38.0°C were enrolled in this study. Blood samples were obtained for bacterial culture, and Salmonella isolates were identified biochemically and confirmed by multiplex polymerase chain reaction (PCR). Antimicrobial susceptibility of all Salmonella isolates was performed by disk diffusion test, and minimum inhibitory concentrations (MICs) against ciprofloxacin were measured by Etest. All Salmonella isolates with reduced susceptibility to ciprofloxacin (MIC > 0.06 µg/mL) were screened for mutations in quinolone resistance-determining regions in target genes, and the presence of plasmid-mediated quinolone resistance (PMQR) genes was assessed by PCR. RESULTS A total of 8161 blood cultures were performed, and 100 (1.2%) S. Typhi, 2 (<0.1%) Salmonella enterica serovar Paratyphi A, and 27 (0.3%) nontyphoid Salmonella (NTS) were isolated. Multidrug-resistant S. Typhi were isolated in Kenya (79% [n = 38]) and Tanzania (89% [n = 8]) only. Reduced ciprofloxacin-susceptible (22% [n = 11]) S. Typhi were isolated only in Kenya. Among those 11 isolates, all had a Glu133Gly mutation in the gyrA gene combined with either a gyrA (Ser83Phe) or gyrB mutation (Ser464Phe). One Salmonella Paratyphi A isolate with reduced susceptibility to ciprofloxacin was found in Senegal, with 1 mutation in gyrA (Ser83Phe) and a second mutation in parC (Ser57Phe). Mutations in the parE gene and PMQR genes were not detected in any isolate. CONCLUSIONS Salmonella Typhi with reduced susceptibility to ciprofloxacin was not distributed homogenously throughout SSA. Its prevalence was very high in Kenya, and was not observed in other study countries. Continuous monitoring of antimicrobial susceptibility is required to follow the potential spread of antimicrobial-resistant isolates throughout SSA.
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Affiliation(s)
- Hassan M Al-Emran
- Bernhard Nocht Institute for Tropical Medicine German Center for Infection Research, partner site Hamburg-Borstel-Lübeck, Hamburg, Germany
| | - Daniel Eibach
- Bernhard Nocht Institute for Tropical Medicine German Center for Infection Research, partner site Hamburg-Borstel-Lübeck, Hamburg, Germany
| | - Ralf Krumkamp
- Bernhard Nocht Institute for Tropical Medicine German Center for Infection Research, partner site Hamburg-Borstel-Lübeck, Hamburg, Germany
| | - Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stephen Baker
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Holly M Biggs
- Division of Infectious Diseases and International Health, Duke University Medical Center Duke Global Health Institute, Duke University, Durham, North Carolina
| | | | - Robert F Breiman
- Kenya Medical Research Institute-Centers for Disease Control and Prevention Kenya Collaboration, Nairobi Global Health Institute, Emory University, Atlanta, Georgia
| | - John D Clemens
- International Vaccine Institute, Seoul, Republic of Korea International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - John A Crump
- Division of Infectious Diseases and International Health, Duke University Medical Center Duke Global Health Institute, Duke University, Durham, North Carolina Kilimanjaro Christian Medical Centre, Moshi, Tanzania Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | - Jessica Deerin
- International Vaccine Institute, Seoul, Republic of Korea
| | - Denise Myriam Dekker
- Bernhard Nocht Institute for Tropical Medicine German Center for Infection Research, partner site Hamburg-Borstel-Lübeck, Hamburg, Germany
| | - Amy Gassama Sow
- Institut Pasteur de Dakar, Université Cheikh Anta Diop de Dakar, Senegal
| | - Julian T Hertz
- Division of Infectious Diseases and International Health, Duke University Medical Center Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Justin Im
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | | | - Frank Konings
- International Vaccine Institute, Seoul, Republic of Korea
| | - Sandra Valborg Løfberg
- Bandim Health Project, Bissau, Guinea-Bissau Research Center for Vitamins and Vaccines, Copenhagen, Denmark
| | - Christian G Meyer
- Bernhard Nocht Institute for Tropical Medicine Institute of Tropical Medicine, Eberhard-Karls University Tübingen, Germany
| | - Eric D Mintz
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joel M Montgomery
- Kenya Medical Research Institute-Centers for Disease Control and Prevention Kenya Collaboration, Nairobi
| | - Beatrice Olack
- Kenya Medical Research Institute-Centers for Disease Control and Prevention Kenya Collaboration, Nairobi
| | - Gi Deok Pak
- International Vaccine Institute, Seoul, Republic of Korea
| | - Ursula Panzner
- International Vaccine Institute, Seoul, Republic of Korea
| | - Se Eun Park
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | | | | | | | - Heidi Schütt-Gerowitt
- International Vaccine Institute, Seoul, Republic of Korea Institute of Medical Microbiology, University of Cologne, Germany
| | - Emmanuel Sampo
- Institute of Medical Microbiology, University of Cologne, Germany
| | | | - Adama Tall
- Institut Pasteur de Dakar, Université Cheikh Anta Diop de Dakar, Senegal
| | | | | | - Jürgen May
- Bernhard Nocht Institute for Tropical Medicine German Center for Infection Research, partner site Hamburg-Borstel-Lübeck, Hamburg, Germany
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
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Panzner U, Pak GD, Aaby P, Adu-Sarkodie Y, Ali M, Aseffa A, Baker S, Bjerregaard-Andersen M, Crump JA, Deerin J, Cruz Espinoza LM, Gasmelseed N, Heriniaina JN, Hertz JT, Im J, von Kalckreuth V, Keddy KH, Lankoande B, Løfberg S, Meyer CG, Oresto MM, Park JK, Park SE, Rakotozandrindrainy R, Sarpong N, Soura AB, Gassama Sow A, Tall A, Teferi M, Worku A, Yeshitela B, Wierzba TF, Marks F. Utilization of Healthcare in the Typhoid Fever Surveillance in Africa Program. Clin Infect Dis 2016; 62 Suppl 1:S56-68. [PMID: 26933023 PMCID: PMC4772834 DOI: 10.1093/cid/civ891] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Assessing healthcare utilization is important to identify weaknesses of healthcare systems, to outline action points for preventive measures and interventions, and to more accurately estimate the disease burden in a population. METHODS A healthcare utilization survey was developed for the Typhoid Fever Surveillance in Africa Program (TSAP) to adjust incidences of salmonellosis determined through passive, healthcare facility-based surveillance. This cross-sectional survey was conducted at 11 sites in 9 sub-Saharan African countries. Demographic data and healthcare-seeking behavior were assessed at selected households. Overall and age-stratified percentages of each study population that sought healthcare at a TSAP healthcare facility and elsewhere were determined. RESULTS Overall, 88% (1007/1145) and 81% (1811/2238) of the population in Polesgo and Nioko 2, Burkina Faso, respectively, and 63% (1636/2590) in Butajira, Ethiopia, sought healthcare for fever at any TSAP healthcare facility. A far smaller proportion-namely, 20%-45% of the population in Bissau, Guinea-Bissau (1743/3885), Pikine, Senegal (1473/4659), Wad-Medani, Sudan (861/3169), and Pietermaritzburg, South Africa (667/2819); 18% (483/2622) and 9% (197/2293) in Imerintsiatosika and Isotry, Madagascar, respectively; and 4% (127/3089) in Moshi, Tanzania-sought healthcare at a TSAP healthcare facility. Patients with fever preferred to visit pharmacies in Imerintsiatosika and Isotry, and favored self-management of fever in Moshi. Age-dependent differences in healthcare utilization were also observed within and across sites. CONCLUSIONS Healthcare utilization for fever varied greatly across sites, and revealed that not all studied populations were under optimal surveillance. This demonstrates the importance of assessing healthcare utilization. Survey data were pivotal for the adjustment of the program's estimates of salmonellosis and other conditions associated with fever.
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Affiliation(s)
- Ursula Panzner
- International Vaccine Institute, Seoul, Republic of Korea
| | - Gi Deok Pak
- International Vaccine Institute, Seoul, Republic of Korea
| | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau
| | - Yaw Adu-Sarkodie
- Kumasi Centre for Collaborative Research in Tropical Medicine School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea Johns Hopkins University, Baltimore, Maryland
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Morten Bjerregaard-Andersen
- Bandim Health Project, Bissau, Guinea-Bissau Research Center for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
| | - John A Crump
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania Centre for International Health, University of Otago, Dunedin, New Zealand Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina
| | - Jessica Deerin
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | | | - Julian T Hertz
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina
| | - Justin Im
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Karen H Keddy
- National Institute for Communicable Diseases Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Christian G Meyer
- Institute of Tropical Medicine, Eberhard-Karls University, Tübingen, Germany
| | | | - Jin Kyung Park
- International Vaccine Institute, Seoul, Republic of Korea
| | - Se Eun Park
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Nimako Sarpong
- Kumasi Centre for Collaborative Research in Tropical Medicine
| | | | - Amy Gassama Sow
- Institute Pasteur de Dakar Université Cheikh Anta Diop de Dakar, Senegal
| | | | | | | | | | | | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
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Hertz JT, Lescallette RD, Barrett TW, Ward MJ, Self WH. External validation of an ED protocol for reflex urine culture cancelation. Am J Emerg Med 2015; 33:1838-9. [PMID: 26472506 DOI: 10.1016/j.ajem.2015.09.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/17/2015] [Accepted: 09/18/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- Julian T Hertz
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232
| | - Richard D Lescallette
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232
| | - Tyler W Barrett
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232
| | - Michael J Ward
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232
| | - Wesley H Self
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232.
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Hertz JT, Reardon JM, Rodrigues CG, de Andrade L, Limkakeng AT, Bloomfield GS, Lynch CA. Acute myocardial infarction in sub-Saharan Africa: the need for data. PLoS One 2014; 9:e96688. [PMID: 24816222 PMCID: PMC4016044 DOI: 10.1371/journal.pone.0096688] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 04/10/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Trends in the prevalence of acute myocardial infarction in sub-Saharan Africa have not been well described, despite growing recognition of the increasing burden of cardiovascular disease in low- and middle-income countries. The aim of this systematic review was to describe the prevalence of acute myocardial infarction in sub-Saharan Africa. METHODS We searched PubMed, EMBASE, Global Health Archive, CINAHL, and Web of Science, and conducted reference and citation analyses. Inclusion criteria were: observational studies, studies that reported incidence or prevalence of acute myocardial infarction, studies conducted in sub-Saharan Africa, and studies that defined acute myocardial infarction by EKG changes or elevation of cardiac biomarkers. Studies conducted prior to 1992 were excluded. Two independent reviewers analyzed titles and abstracts, full-texts, and references and citations. These reviewers also performed quality assessment and data extraction. Quality assessment was conducted with a validated scale for observational studies. FINDINGS Of 2292 records retrieved, seven studies met all inclusion criteria. These studies included a total of 92,378 participants from highly heterogeneous study populations in five different countries. Methodological quality assessment demonstrated scores ranging from 3 to 7 points (on an 8-point scale). Prevalence of acute myocardial infarction ranged from 0.1 to 10.4% among the included studies. INTERPRETATION There is insufficient population-based data describing the prevalence of acute myocardial infarction in sub-Saharan Africa. Well-designed registries and surveillance studies that capture the broad and diverse population with acute myocardial infarction in sub-Saharan Africa using common diagnostic criteria are critical in order to guide prevention and treatment strategies. REGISTRATION Registered in International Prospective Register of Systematic Reviews (PROSPERO) Database #CRD42012003161.
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Affiliation(s)
- Julian T. Hertz
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Joseph M. Reardon
- Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
| | - Clarissa G. Rodrigues
- Department of Surgery, Duke University, Durham, North Carolina, United States of America
- Instituto de Cardiologia do RS – Fundação Universitária de Cardiologia, Porto Alegre, RS, Brazil
| | - Luciano de Andrade
- Department of Surgery, Duke University, Durham, North Carolina, United States of America
- Universidade Estadual do Oeste do Paraná (UNIOESTE), Foz do Iguaçú, PR, Brazil
| | - Alexander T. Limkakeng
- Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
| | - Gerald S. Bloomfield
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
- Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Catherine A. Lynch
- Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Global Health Institute, Duke University, Durham, North Carolina, United States of America
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