Availability, cost and affordability of essential cardiovascular disease medicines in the south west region of Cameroon: Preliminary findings from the Cameroon science for disease study

BACKGROUND

More than 80% of premature deaths due to cardiovascular disease (CVD) occur in low- and middle-income countries. However, access to, and affordability of medications remain a challenge in these countries.

OBJECTIVE

To assess the availability, cost and affordability of essential cardiovascular medicines in the South West region of Cameroon.

METHODS

In an audit of 63 medicine outlets, twenty-six essential medicines were surveyed using the World Health Organisation (WHO) /Health Action International methodology. Availability, costs and the ratio of the median price to the international reference price were evaluated in public, confessional, private facility medicine outlets, and community pharmacies. Affordability was assessed by calculating the number of days' wages it will cost the lowest-paid unskilled government worker to purchase a month worth of chronic treatment.

FINDINGS

Availability ranged from 25.3% (public facility outlets) to 49.2% (community pharmacies) for all medicines. This was higher in urban and semi-urban compared to rural outlets. Cost of medicines was highest in community pharmacies and lowest in public facility outlets. Aspirin, digoxin, furosemide, hydrochlorothiazide and nifedipine were affordable (cost a day's wage or less). Medicines for heart failure and dyslipidaemia (beta blockers, angiotensin converting enzyme inhibitors and statins) required 2-5 days and 6-13 days wages respectively for one month of chronic treatment.

CONCLUSION

Overall availability of CVD essential medicines was lower than WHO recommendations, and medicines were largely unaffordable. While primary prevention is pivotal, improving availability and affordability of medicines especially for public facilities would provide additional benefit in curbing the CVD burden.

Prevalence and determinants of abnormal glucose metabolism in urban and rural secondary schools in Cameroon: A cross-sectional study in a sub-Saharan Africa setting

INTRODUCTION

The incidence of Diabetes in children and teenagers increased by 30.2% between 2001 and 2009, with the main cause being an increase in the prevalence of overweight and obesity. Despite its high morbidity and mortality, few studies in Cameroon have focused on the study of abnormal glucose metabolism in schools.

METHODOLOGY

This cross-sectional study was carried out in three schools institutions of two health districts selected from a three-stage cluster sampling survey-which consisted of a simple draw without discount for department selection, a simple random survey for the choice of health districts, and finally a simple random survey for the choice of schools institutions.

RESULTS

Among the 815 participants, the prevalence of impaired fasting glucose and diabetes was 34.1% and 1.8% respectively. Glucose metabolism abnormalities were significantly higher in rural area than in urban areas (40% vs. 31.6%, p=0.016), and were significantly associated with abdominal obesity (p=0.027). Overweight and obesity were significantly higher in rural areas (p=0.0002), as well as abdominal obesity (p=0.0004).

CONCLUSION

Abnormalities of glucose metabolism are a major health problem in schools in Cameroon. Thus, it is urgent to develop a health policy involving teachers and parents in the fight against overweight and obesity in schools.

Late mortality after cardiac interventions over 10-year period in two Cameroonian government-owned hospitals

Background

Cardiac surgery is a growing activity in Sub-Saharan Africa, however, data related to long-term mortality are scarce. We aimed to analyze outcome data of cardiac interventions in two hospitals in Cameroon over 10 years' period.

Methods

we conducted a retrospective analytical and descriptive study at the Douala General Hospital and Yaoundé General Hospital. All patients operated between January 2007 and December 2017, or their families were contacted by phone between January and April 2018 for a free of charges medical examination.

Results

Of a total of 98 patients operated during the study period, 8 (8.2%) were lost to follow-up. Finally, 90 patients [49 (54.4%) women and 41 (45.6%)] men were included. The mean age was 49±22 years (range, 13-89 years). The surgical indications were valvular heart diseases in 37 (41.1%) cases, congenital heart diseases in 11 (12.2%) cases, chronic constrictive pericarditis in 4 (4.4%) cases, and intra cardiac tumor in 1 (1.1%) case. Valve replacement was the most common type of surgery carried out in 37 (41.1%) cases-mostly with mechanical prosthesis. Pacemaker-mostly dual-chambers were implanted in 36 (40.0%) patients. The median follow-up was 26 months. The overall late mortality was 5.7%, and the overall survival rates at 5 and 10 years were 95.5% and 94.4% respectively. The overall survival rates at 5 and 10 years for mechanical valve prosthesis were 93.3% and 90% respectively. The survival at 10 years was 100% for patients with bioprosthesis. The survival rates at 10 years were 94.1% and 100% respectively for dual and single chamber pacemaker.

Conclusions

Long-term outcome of cardiac surgery in hospitals in Cameroon are acceptable with low mortality rate. However, outcome metrics beyond mortality should be implemented for a prospective data collection.

Prevalence and risk factors of peripheral artery disease in black Africans with HIV infection: a cross-sectional hospital-based study

Background

The prevalence of peripheral artery disease (PAD) is not well known among HIV-infected patients in Africa. The aim of this study was to determine the prevalence and associated risk factors of PAD among HIV-infected patients at the Douala General Hospital (DGH).

Methods

This was a cross-sectional descriptive and analytic study between November 2015 and April 2016. We recruited patients aged ≥21 years, diagnosed with HIV infection, and who were receiving care at the DGH. We collected sociodemographic data and past medical history of patients. We measured their ankle-brachial index (ABI). We defined PAD as an ABI <0.9. We also measured their fasting blood glucose and lipid profile.

Results

We recruited 144 patients for this study. The mean age was 46±9 years, and 72.2% were females. Of which, 89% were on antiretroviral treatment (ARV). Their mean CD4+ T lymphocytes count was 451±306 cells/mm³. Their mean ABI was 1.12±0.17 and 1.07±0.11, respectively, on the left and right legs (P>0.05). The prevalence of PAD was 6.9% (95% CI: 3.4–12.4), and 60% of patients with PAD were symptomatic. After adjusting for age, sex and ARV, ARV treatment was protective (aOR: 0.18, [95% CI: 0.04–0.82], P=0.034), while WHO stages III or IV was associated with PAD (aOR: 11.1, [95% CI: 2.19–55.92], P=0.004).

Conclusion

The prevalence of PAD was not as high as expected in this group of patients with high cardiovascular risk infected with HIV. Advanced HIV disease was associated with PAD, while ARV was protective.

Arterial stiffness in black African ancestry patients with chronic kidney disease living in Cameroon

Background

Increased aortic pulse wave velocity (PWV), a direct measure of arterial stiffness (AS) is an independent predictor of cardiovascular events (CVEs) in chronic kidney disease (CKD) patients. This study assessed the patterns of PWV among Cameroonian patients with CKD in whom that marker of early vascular aging has not been explored so far.

Methods

We enrolled 150 Black African patients (mean age: 52±15 years, 56.7% males) with CKD in a cross-sectional study conducted at Douala General Hospital, Douala, Cameroon. Sociodemographic, anthropometric and biologic variables, blood pressure (BP) and PWV were recorded in all participants. Estimated aortic PWV was measured using a Mobil-O-Graph automatic brachial oscillometric device.

Results

PWV increased with aging (P<0.0001), and PWV adjusted for age, sex, body mass index and mean arterial BP (MAP) was higher in non-dialysed (n=90) than in hemodialysed (n=60) patients, even in pre-dialysis: 8.5±2.0 vs. 7.9±1.4 m/s (P=0.026); and in post-dialysis: 8.5±2.0 vs. 7.8±1.5 m/s (P=0.008). The mean PWV of all study participants was 8.2±1.8 m/s, with 61.3% of patients having a PWV ≥8.2 m/s, indicative of subclinical damage to the aorta, which was more pronounced in non-dialysis (67.8%) than in hemodialysis (53.3%) patients (P=0.033). Multivariable analysis performed in all participants revealed that advanced age, MAP and tobacco use were independently associated with PWV (all P<0.05).

Conclusions

Our findings suggest increased AS in Cameroonian CKD non-dialyzed as compared to dialyzed patients. Slower PWV in patients on maintenance hemodialysis suggests improvement of aortic distensibility following dialysis. However, further large-scale studies are needed to confirm our findings and to improve understanding of the underlying mechanisms of arterial stiffening in black African ancestry patients with CKD.

Electrophoretic Profile of Serum Proteins Using Capillary Technique in Patients Attending the Douala General Hospital, Cameroon

Background: Electrophoresis of serum proteins is an orientation examination routinely used in clinical practice. For a few years, agarose gel electrophoresis has tended to be replaced with capillary electrophoresis owing to an increase in the accuracy of results. However, this technique is uncommon and is not widely used in Cameroon. Objectives: The research aimed at studying the electrophoretic profile of serum proteins using capillary technique among patients attending the Douala General Hospital, Cameroon. Methods: Capillary electrophoresis was used to carry out tests on blood samples from any inpatients and outpatients and fasting for 8-12 hours. Capillary electrophoresis of serum samples was used for the separation of proteins into six fractions and the total protidemia of each serum samples was determined using the Biuret method. Results were interpreted by observing the shape of curves and quantitative variations in each fraction of the different serum proteins. Results: A total of 311 patients participated in the study. The sampled population aged 50±18 years on average and consisted of 55.3% men and 44.7% women. All capillary electrophoresis profiles presented six protein fractions, namely, albumin, alpha (1 and 2), beta (1 and 2) and gamma globulins. Pathological disorders were diagnosed in 290 patients and 21 patients had normal results. Inflammatory syndromes accounted for 63.34% and monoclonal gammopathies for 10.29% the main pathological disorder identified. Conclusion: Capillary electrophoresis provides a more precise identification of biological syndromes and clear distinction of the six fractions of each protein. Monoclonal profiles and inflammatory syndromes were well detected. A prevalence of 10.29% was determined for gammopathies.

Effects of phloroglucinol on the active phase of labour (EPAL trial): a single blinded randomised controlled trial in a tertiary hospital in sub-Sahara Africa

Introduction

One of the most recognized factors of maternal and neonatal outcome pertaining to the peripartum period is the duration of labour. Finding a drug that will decrease the duration of labour with no effects on mother and foetus will be welcomed. Thereby in this study we aimed to evaluate the effects of phloroglucinol on the duration of the active phase of labour.

Methods

We did a single blinded placebo controlled randomised 1:1 parallel designed superiority trial between January and June 2017 in Douala general hospital. Participants greater than 18 years with singleton uncomplicated pregnancy who consented following randomisation, were administered either 80mg/8ml intravenous phloroglucinol or 8ml of sterile water when in active labour. The primary outcome was the duration of labour. Modified intention to treat analysis was done with the level of significance set at a p value of 0.05.

Results

122 participants received the intervention. The mean total duration labour in the treatment and placebo group were 216.8 ± 38.7 and 358.5 ± 65.8 respectively (p value = 0.243). The mean duration of the active phase of labour in the treatment and placebo group were 183.0±35.6 and 316.0±52.2 respectively (p value = 0.046). The mean rate of cervical dilatation in the treatment and placebo group were 2.1 ± 0.4 and 1.3 ± 0.4 respectively (p value = 0.322). There was no difference in maternal and foetal outcomes between the two groups.

Conclusion

Phloroglucinol shortens the duration of active phase of labour by about 2 hours (42%). It is safe to mother and baby and does not cause adverse foetal or maternal outcomes.

Multiple cerebral infarction revealing Takayasu's disease: a case report in a 32-year-old man from Cameroon, sub-Saharan Africa

This case suggests that young patients with few vascular risk factors, and who present with acute stroke syndrome involving more than one vascular territory should be screened for an inflammatory or infectious cause.

Prevalence and risk factors of chronic kidney disease in newly diagnosed and untreated hypertensive patients in cameroon: A cross-sectional study

Chronic kidney disease (CKD) has emerged as a worldwide problem and is a major cause for comorbidity in hypertensive patients. In an attempt to enhance awareness and to help in establishing preventive measures and care, it is necessary to describe CKD among newly diagnosed and untreated hypertensive patients. We conducted a cross-sectional study to describe the characteristics of CKD among newly diagnosed, treatment naïve, hypertensive patients in four health-care centers in the city of Douala, Cameroon. Sociodemographic and biological data were collected and serum creatinine was measured by enzymatic - colorimetric methods. We calculated estimated glomerular filtration rate (eGFR) by the Modification of Diet in Renal Disease equation and described CKD as eGFR <60 mL/min/1.73 m2. Logistic regression was further used to develop early clues of association. We included 839 newly diagnosed hypertensive treatment naïve patients, among which 412 (49.1%) men. The mean [±standard deviation (SD)] age was 51 (±11) years and was higher among those with CKD. Seventy-six had a family history of hypertension and 65 were known diabetic patients. Mean (±SD) eGFR was 94.4 (±33.3) mL/min and the prevalence of CKD was 12.4% (104/839). From multivariate logistic regression, age >55 years [OR: 5.29 (3.33-8.42)], obesity [OR: 0.15 (0.10-0.26)], kalemia [OR: 1.33 (1.03-1.72)] were independently associated to CKD. CKD is a common condition in newly diagnosed and untreated hypertensive patients in Cameroon. Individuals with hypertension should be carefully evaluated for the presence of CKD, especially those with decreased GFR.

Outcome of permanent vascular access for haemodialysis in patients with end-stage renal disease in Cameroon: results from the pilot experience of the Douala general hospital

Background Chronic Kidney disease is a major health problem in the world. Native arteriovenous Fistula (AVF) is well established as the best vascular access for haemodialysis. Little is known about the outcome of AVF in sub-Saharan Africa. We aim to analyze the outcome of patients undergoing AVF creation during the pilot program established at the Douala general hospital (DGH). Method This was hospital-based, longitudinal study with a retrospective phase (April 2010-January 2014) and a prospective phase (January 2014-April 2014). All consecutive patients operated for AVF creation were included in this study. Socio-demographics data, functionality, and complications were analyzed. Results Eighty-one patients including 52 men were enrolled in this study (49 prospectively and 32 retrospectively). The mean age was 52, 3 years (range 18-81 years). Hypertension (66, 7%), diabetes (17, 3%), and HIV (8, 6%) were the most observed co-morbidities. About 96.3% of AVF were native and 3.7% were prosthetic graft. Radiocephalic AVF was performed at a rate of 77.8%. The primary function rate was 97.7% and the mean follow-up period 43.4 weeks. The overall rate of complications was 44.4% of whom 30.5% were early, 30.5% secondary, and 39% lasted. The treatment of these complications was conservative in 48.7% of cases. Conclusions The results of the pilot program of AVF creation at the DGH are encouraging. However, the sustainability of this project requires human capacity building.

The way forward for clinical research in Cameroon: first scientific and research day in Douala, 2014

There is a huge need for health research to support contextually relevant health service and policy solutions to better the health of populations in sub-Saharan Africa. This need contrasts with the very timid engagement of healthcare practitioners in research in the region.It is against this background that the Douala General Hospital (a tertiary-care hospital in Cameroon), under the stewardship of its chief executive officer, organised the first annual scientific and research day in October 2014. This maiden event saw the participation of local research leaders and the eminent director of the South African Hatter Institute for Cardiovascular Research in Africa, who co-chaired the event. The aim was to educate students, clinicians and junior researchers on the importance of clinical research and evidence-based medicine around the leading theme of the event: action for clinical research and good medical practice.Several abstracts were presented, covering various aspects of medicine, including cardiology, rheumatology, paediatrics, pulmonology, HIV medicine, and obstetrics and gynaecology, together with key lectures on cardiac disease and pregnancy, and plenary sessions on research methodology, scientific writing and publishing. It is hoped that this event will enhance clinical research and the dissemination of research findings to improve evidence-based clinical practice in the country.

Tuberculous meningitis: presentation, diagnosis and outcome in hiv-infected patients at the douala general hospital, cameroon: a cross sectional study

INTRODUCTION

Tuberculous meningitis (TBM) the most fatal presentation of tuberculosis (TB) especially in HIV-infected patients is a real diagnostic and therapeutic challenge worldwide. In Cameroon where HIV and TB are amongst the leading public health problems, the magnitude of TBM has not been defined. Therefore, the objective of this cross sectional study was to describe the presentation and in-hospital outcome of TBM among HIV patients in Douala as well as its diagnostic difficulties.

METHODS

We did a clinical case note analysis of all HIV-1 infected patients treated for TBM in the Internal medicine unit of the Douala General Hospital, between January 1st 2004 and December 31st 2009. The diagnosis of TBM was made using clinical, laboratory [cerebrospinal fluid (CSF) analysis] and/or brain computerised tomographic (CT) scan features.

RESULTS

During the study period, 8% (54/672) of HIV-infected patients had TBM. Their mean age was 40.3 ± 12.7 years. The main presenting complaint was headache in 74.1% (40/54) of patients. Their median CD4 cell count was 16 cells/mm3 (IQR: 10 - 34). CSF analysis showed median protein levels of 1.7 g/l (IQR: 1.3 - 2.2), median glucose level of 0.4 g/l (IQR: 0.3 - 0.5) and median white cell count (WCC) count of 21 cells/ml (IQR: 12 - 45) of which mononuclear cells were predominant in 74% of CSF. Acid fast bacilli were found in 1.9% (1/54) of CSF samples. On CT scan hydrocephalus was the main finding in 70.6% (24/34) of patients. In hospital case fatality was 79.6% (43/54).

CONCLUSION

TBM is a common complication in HIV-infected patients in Douala with high case fatality. Its presumptive diagnosis reposes mostly on CSF analysis, so clinicians caring for HIV patients should not hesitate to do lumbar taps in the presence of symptoms of central nervous system disease.

Toxoplasma encephalitis in HIV/AIDS patients admitted to the Douala general hospital between 2004 and 2009: a cross sectional study

Background

It is estimated that about a third of the world’s population is chronically infected with Toxoplasma gondii. Toxoplasma encephalitis (TE), which occurs as a reactivation of quiescent chronic infection, is one of the leading causes of central nervous system (CNS) infection in AIDS. Its diagnosis in most centres still remains difficult. We opted to describe the clinical and radiological features of TE as well as in-hospital outcome and its associated factors.

Methods

We carried out a cross sectional study on the clinical case notes of adult patients admitted and treated for TE at the Douala General Hospital, Cameroon between January 1^st 2004 to December 31^st 2009.

Results

Of 672 patients admitted during the study period, 14.4% (97/672) had TE. The mean age was 36.9 ± 14.1 years and the median CD4 cell count was 68/mm³ (IQR): 43 – 103). Headache and fever were the most common presenting symptoms in 92.8% (90/97) and 87.6% (85/97) of patients. Annular contrast enhanced lesions were the most common brain scan finding in 81.4% (79/97) of patients. In-hospital mortality was 29.9% (29/97). Altered sensorium, presence of focal signs, neck stiffness and low CD4 cell count were factors associated with mortality. Adjusting for low CD4 count, altered sensorium remained strongly associated with fatality, adjusted odd ratio (AOR) 3.5 (95% CI 1.2 – 10.5).

Conclusion

Toxoplasma encephalitis is common among AIDS patients in Douala. Its high case fatality warrants adequate and compliant prophylactic therapy in severely immune depressed patients as well as early initiation of antiretroviral therapy in HIV-infected patients.

Prevalence and determinants of electrocardiographic abnormalities in sub-Saharan African individuals with type 2 diabetes

Aim

This study assessed the prevalence and determinants of electrocardiographic abnormalities in a group of type 2 diabetes patients recruited from two referral centres in Cameroon.

Methods

A total of 420 patients (49% men) receiving chronic diabetes care at the Douala General and Yaoundé Central hospitals were included. Electrocardiographic abnormalities were investigated, identified and related to potential determinants, with logistic regressions.

Results

The mean age and median duration of diagnosis were 56.7 years and four years, respectively. The main electrocardiographic aberrations (prevalence %) were: T-wave abnormalities (20.9%), Cornell product left ventricular hypertrophy (16.4%), arrhythmia (16.2%), ischaemic heart disease (13.6%), conduction defects (11.9%), QTc prolongation (10.2%) and ectopic beats (4.8%). Blood pressure variables were consistently associated with all electrocardiographic abnormalities. Diabetes-specific factors were associated with some abnormalities only.

Conclusions

Electrocardiographic aberrations in this population were dominated by repolarisation, conduction defects and left ventricular hypertrophy, and were more related to blood pressure than diabetes-specific factors.