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Khan AI, Mack JA, Salimuzzaman M, Zion MI, Sujon H, Ball RL, Maples S, Rashid MM, Chisti MJ, Sarker SA, Biswas D, Hossin R, Bardosh KL, Begum YA, Ahmed A, Pieri D, Haque F, Rahman M, Levine AC, Qadri F, Flora MS, Gurka MJ, Nelson EJ. Electronic decision support and diarrhoeal disease guideline adherence (mHDM): a cluster randomised controlled trial. Lancet Digit Health 2021; 2:e250-e258. [PMID: 33328057 DOI: 10.1016/s2589-7500(20)30062-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/20/2020] [Accepted: 03/03/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Acute diarrhoeal disease management often requires rehydration alone without antibiotics. However, non-indicated antibiotics are frequently ordered and this is an important driver of antimicrobial resistance. The mHealth Diarrhoea Management (mHDM) trial aimed to establish whether electronic decision support improves rehydration and antibiotic guideline adherence in resource-limited settings. METHODS A cluster randomised controlled trial was done at ten district hospitals in Bangladesh. Inclusion criteria were patients aged 2 months or older with uncomplicated acute diarrhoea. Admission orders were observed without intervention in the pre-intervention period, followed by randomisation to electronic (rehydration calculator) or paper formatted WHO guidelines for the intervention period. The primary outcome was rate of intravenous fluid ordered as a binary variable. Generalised linear mixed-effect models, accounting for hospital clustering, served as the analytical framework; the analysis was intention to treat. The trial is registered with ClinicalTrials.gov (NCT03154229) and is completed. FINDINGS From March 11 to Sept 10, 2018, 4975 patients (75·6%) of 6577 screened patients were enrolled. The intervention effect for the primary outcome showed no significant differences in rates of intravenous fluids ordered as a function of decision-support type. Intravenous fluid orders decreased by 0·9 percentage points for paper electronic decision support and 4·2 percentage points for electronic decision support, with a 4·2-point difference between decision-support types in the intervention period (paper 98·7% [95% CI 91·8-99·8] vs electronic 94·5% [72·2-99·1]; pinteraction=0·31). Adverse events such as complications and mortality events were uncommon and could not be statistically estimated. INTERPRETATION Although intravenous fluid orders did not change, electronic decision support was associated with increases in the volume of intravenous fluid ordered and decreases in antibiotics ordered, which are consistent with WHO guidelines. FUNDING US National Institutes of Health.
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Affiliation(s)
- Ashraful I Khan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Jasmine A Mack
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, USA
| | - M Salimuzzaman
- Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Mazharul I Zion
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Hasnat Sujon
- Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Robyn L Ball
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Stace Maples
- Geospatial Center, Stanford University Libraries, Stanford, CA, USA
| | - Md Mahbubur Rashid
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammod J Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shafiqul A Sarker
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Debashish Biswas
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Raduan Hossin
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Kevin L Bardosh
- Department of Anthropology, University of Florida, Gainesville, FL, USA; Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
| | - Yasmin A Begum
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Azimuddin Ahmed
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Dane Pieri
- Independent Technology Developer, San Francisco, CA, USA
| | - Farhana Haque
- Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh; Institute for Global Health, University College London, London, UK
| | - Mahmudur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Adam C Levine
- Department of Emergency Medicine, Brown University, Providence, RI, USA
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Meerjady S Flora
- Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Matthew J Gurka
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, USA
| | - Eric J Nelson
- Department of Pediatrics, University of Florida, Gainesville, FL, USA; Department of Environmental and Global Health, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, CA, USA.
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Hamill L, Picozzi K, Fyfe J, von Wissmann B, Wastling S, Wardrop N, Selby R, Acup CA, Bardosh KL, Muhanguzi D, Kabasa JD, Waiswa C, Welburn SC. Evaluating the impact of targeting livestock for the prevention of human and animal trypanosomiasis, at village level, in districts newly affected with T. b. rhodesiense in Uganda. Infect Dis Poverty 2017; 6:16. [PMID: 28162093 PMCID: PMC5292814 DOI: 10.1186/s40249-016-0224-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 03/03/2016] [Accepted: 12/15/2016] [Indexed: 11/24/2022] Open
Abstract
Background Uganda has suffered from a series of epidemics of Human African Trypanosomiasis (HAT), a tsetse transmitted disease, also known as sleeping sickness. The area affected by acute Trypanosoma brucei rhodesiense HAT (rHAT) has been expanding, driven by importation of infected cattle into regions previously free of the disease. These regions are also affected by African Animal Trypanosomiasis (AAT) demanding a strategy for integrated disease control. Methods In 2008, the Public Private Partnership, Stamp Out Sleeping Sickness (SOS) administered a single dose of trypanocide to 31 486 head of cattle in 29 parishes in Dokolo and Kaberamaido districts. This study examines the impact of this intervention on the prevalence of rHAT and AAT trypanosomes in cattle from villages that had (HAT+ve) or had not (HAT-ve) experienced a recent case of rHAT. Cattle herds from 20 villages were sampled and screened by PCR, pre-intervention and 6-months post-intervention, for the presence or absence of: Trypanosoma brucei s.l.; human infective T. b. rhodesiense; Trypanosoma vivax; and Trypanosoma congolense savannah. Results Post-intervention, there was a significant decrease in the prevalence of T. brucei s.l. and the human infective sub-species T. b. rhodesiense in village cattle across all 20 villages. The prevalence of T. b. rhodesiense was reduced from 2.4% to 0.74% (P < 0.0001), with the intervention showing greater impact in HAT-ve villages. The number of villages containing cattle harbouring human infective parasites decreased from 15/20 to 8/20, with T. b. rhodesiense infection mainly persisting within cattle in HAT+ve villages (six/eight). The proportion of T. brucei s.l. infections identified as human infective T. b. rhodesiense decreased after the intervention from 8.3% (95% CI = 11.1–5.9%) to 4.1% (95% CI = 6.8–2.3%). Villages that had experienced a recent human case (HAT+ve villages) showed a significantly higher prevalence for AAT both pre- and post-intervention. For AAT the prevalence of T. vivax was significantly reduced from 5.9% to 0.05% post-intervention while the prevalence of T. congolense increased from 8.0% to 12.2%. Conclusions The intervention resulted in a significant decrease in the prevalence of T. brucei s.l., human infective T. b. rhodesiense and T. vivax infection in village cattle herds. The proportion of T. brucei s.l. that were human infective, decreased from 1:12 T. brucei s.l. infections before the intervention to 1:33 post-intervention. It is clearly more difficult to eliminate T. b. rhodesiense from cattle in villages that have experienced a human case. Evidence of elevated levels of AAT in livestock within village herds is a useful indicator of risk for rHAT in Uganda. Integrated veterinary and medical surveillance is key to successful control of zoonotic rHAT. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0224-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louise Hamill
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Kim Picozzi
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Jenna Fyfe
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Beatrix von Wissmann
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Sally Wastling
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Nicola Wardrop
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Richard Selby
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Christine Amongi Acup
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Kevin L Bardosh
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Dennis Muhanguzi
- Department of Pharmacy, Clinical and Comparative Medicine, School of Veterinary Medicine and Animal Resources, Makerere University, P.O. Box 7062, Kampala, Uganda
| | - John D Kabasa
- Department of Pharmacy, Clinical and Comparative Medicine, School of Veterinary Medicine and Animal Resources, Makerere University, P.O. Box 7062, Kampala, Uganda
| | - Charles Waiswa
- Department of Pharmacy, Clinical and Comparative Medicine, School of Veterinary Medicine and Animal Resources, Makerere University, P.O. Box 7062, Kampala, Uganda.,The Coordinating Office for Control of Trypanosomiasis in Uganda (COCTU), Wandegeya, Plot 76/78 Buganda Road, P.O. Box 16345, Kampala, Uganda
| | - Susan C Welburn
- Edinburgh Infectious Diseases, Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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Ducrotoy MJ, Bardosh KL. How do you get the Rose Bengal Test at the point-of-care to diagnose brucellosis in Africa? The importance of a systems approach. Acta Trop 2017; 165:33-39. [PMID: 27725154 DOI: 10.1016/j.actatropica.2016.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 12/23/2022]
Abstract
Brucellosis is a major neglected zoonotic disease, whose burden both in animals and humans is severely under-reported. Diagnosis in humans identifies cases in order to treat the disease at the individual level. In animals diagnosis is implemented at the population level in the context of appropriate control or eradication strategies. Molecular and bacteriological diagnosis are rarely undertaken in sub-Saharan Africa, at least outside research projects, due to cost, skills and laboratory infrastructure issues. The brucellosis toolbox contains a wide range of serological tests, but the perfect test for use in animals and humans respectively does not exist. Drug and diagnostic discovery for the neglected zoonoses are notoriously poor, and there is limited investment interest in developing new tools for brucellosis diagnosis. But are current tools being used to their full capacity? The rose Bengal test (RBT) stands out as an efficient, practical and very cheap test adapted for use in the resource-poor context. In this paper, we argue that a social science or system's approach to explore the practicality of improving diagnostic capacity at the point-of care in high-risk brucellosis areas of rural Africa may be a step towards solving the issue of under-diagnosis, but this must go hand-in-hand with implementation of control measures at source in the animal reservoir and capacity to treat human cases.
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Affiliation(s)
- Marie J Ducrotoy
- Division of Infection and Pathway Medicine, School of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.
| | - Kevin L Bardosh
- Division of Infection and Pathway Medicine, School of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
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Ducrotoy MJ, Yahyaoui Azami H, El Berbri I, Bouslikhane M, Fassi Fihri O, Boué F, Petavy AF, Dakkak A, Welburn S, Bardosh KL. Integrated health messaging for multiple neglected zoonoses: Approaches, challenges and opportunities in Morocco. Acta Trop 2015; 152:17-25. [PMID: 26299194 DOI: 10.1016/j.actatropica.2015.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/11/2015] [Accepted: 08/14/2015] [Indexed: 11/17/2022]
Abstract
Integrating the control of multiple neglected zoonoses at the community-level holds great potential, but critical data is missing to inform the design and implementation of different interventions. In this paper we present an evaluation of an integrated health messaging intervention, using powerpoint presentations, for five bacterial (brucellosis and bovine tuberculosis) and dog-associated (rabies, cystic echinococcosis and leishmaniasis) zoonotic diseases in Sidi Kacem Province, northwest Morocco. Conducted by veterinary and epidemiology students between 2013 and 2014, this followed a process-based approach that encouraged sequential adaptation of images, key messages, and delivery strategies using auto-evaluation and end-user feedback. We describe the challenges and opportunities of this approach, reflecting on who was targeted, how education was conducted, and what tools and approaches were used. Our results showed that: (1) replacing words with local pictures and using "hands-on" activities improved receptivity; (2) information "overload" easily occurred when disease transmission pathways did not overlap; (3) access and receptivity at schools was greater than at the community-level; and (4) piggy-backing on high-priority diseases like rabies offered an important avenue to increase knowledge of other zoonoses. We conclude by discussing the merits of incorporating our validated education approach into the school curriculum in order to influence long-term behaviour change.
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Affiliation(s)
- M J Ducrotoy
- Division of Infection and Pathway Medicine, Centre for Infectious Diseases, School of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, United Kingdom.
| | - H Yahyaoui Azami
- Institut Agronomique et Vétérinaire Hassan II, BP : 6202, Rabat-Instituts, Morocco; Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - I El Berbri
- Institut Agronomique et Vétérinaire Hassan II, BP : 6202, Rabat-Instituts, Morocco
| | - M Bouslikhane
- Institut Agronomique et Vétérinaire Hassan II, BP : 6202, Rabat-Instituts, Morocco
| | - O Fassi Fihri
- Institut Agronomique et Vétérinaire Hassan II, BP : 6202, Rabat-Instituts, Morocco
| | - F Boué
- ANSES, Laboratoire de la rage et de la faunes auvagede Nancy, Unité de Surveillance Eco-épidémiologique des Animaux Sauvages, Laboratoire national de référence pour Echinococcusspp, 54220 Malzéville cedex, France
| | - A F Petavy
- Department of Parasitology and Medical Mycology, Lyon 1 University, 8 Avenue Rochefeller, 69373 Lyon Cedex 08, France
| | - A Dakkak
- Institut Agronomique et Vétérinaire Hassan II, BP : 6202, Rabat-Instituts, Morocco
| | - S Welburn
- Division of Infection and Pathway Medicine, Centre for Infectious Diseases, School of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, United Kingdom
| | - K L Bardosh
- Division of Infection and Pathway Medicine, Centre for Infectious Diseases, School of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, United Kingdom; Emerging Pathogens Institute, University of Florida, Gainesville, USA
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