WHO/INRUD prescribing indicators among tertiary regional referral hospitals in Dar es Salaam, Tanzania: a call to strengthen antibiotic stewardship programmes

Background

Antibiotic prescribing should be guided by national essential medicines lists (NEMLs) and treatment guidelines; however, there are inadequate data on antibiotic utilization patterns in tertiary hospitals in Tanzania. This study aimed to determine antibiotic prescribing patterns in tertiary hospitals in Dar es Salaam, Tanzania.

Methods

A retrospective cross-sectional study was conducted in three regional referral hospitals. About 200 prescription records from 2020 to 2022 were analysed at each hospital for prescribing patterns using WHO/ International Network of Rational Use of Drugs (INRUD) indicators (1993) and the AWaRe 2021 classification. Factors associated with receiving an antibiotic prescription were assessed using a logistic regression model. Facilities were ranked on prescribing practices using the index of rational drug prescribing (IRDP).

Results

A total of 2239 drugs were prescribed, of which 920 (41.1%) were antibiotics. An average of 3.7 ± 1.5 (optimal: 1.6-1.8) total medicines and 1.53 ± 0.78 antibiotics were prescribed per patient. About 88.0% (528) of the prescriptions contained antibiotics (optimal: 20.0%-26.8%), while 78.2% (413) of all antibiotic prescriptions contained injections (optimal: 13.4%-24.1%). Furthermore, 87.5% (462) of the antibiotics were prescribed in generic names (optimal: 100%), while 98.7% (521) conformed to the NEML (optimal: 100%). Metronidazole was the most frequently prescribed antibiotic (39.2%; n = 134), followed by ceftriaxone (37.1%, n = 127) and amoxicillin/clavulanic acid (8.5%, n = 29).

Conclusions

We found substantial empirical prescribing and overuse of antibiotics exceeding WHO recommendations. Antibiotic overuse varied across the hospitals. Being male, having underlying conditions such as diabetes mellitus, and/or being treated at Temeke hospital were associated with receiving an antibiotic prescription. We recommend strengthening antibiotic stewardship programmes in the studied facilities.

Facilitators for and Barriers to the Implementation of Performance Accountability Mechanisms for Quality Improvement in the Delivery of Maternal Health Services in a District Hospital in Pwani Region, Tanzania

Tanzania experiences a burden of maternal mortality and morbidity. Despite the efforts to institute accountability mechanisms, little is known about quality improvement in the delivery of maternal health services. This study aimed at exploring barriers and facilitators to enforcing performance accountability mechanisms for quality improvement in maternal health services. A case study design was used to conduct semi-structured interviews with thirteen key informants. Data were analyzed using thematic analyses. The findings were linked to two main performance accountability mechanisms: maternal and perinatal death reviews (MPDRs) and monitoring and evaluation (M&E). Prioritization of the maternal health agenda by the government and the presence of maternal death review committees were the main facilitators for MPDRs, while negligence, inadequate follow-up, poor record-keeping, and delays were the main barriers facing MPDRs. M&E was facilitated by the availability of health management information systems, day-to-day ward rounds, online ordering of medicines, and the use of biometrics. Non-use of data for decision-making, supervision being performed on an ad hoc basis, and inadequate health workforce were the main barriers to M&E. The findings underscore that barriers to the performance accountability mechanisms are systemic and account for limited effectiveness in the improvement of quality of care.

Asymptomatic bacteriuria among pregnant women attending antenatal care at Mbale Hospital, Eastern Uganda

Background

Asymptomatic bacteriuria in pregnancy (ASBP) is associated with adverse pregnancy outcomes such as pyelonephritis, preterm or low birth weight delivery if untreated. The aim of this study was to determine the prevalence of asymptomatic bacteriuria, the isolated bacterial agents, and their antibiotic sensitivity patterns in pregnant women attending antenatal care at Mbale Hospital.

Methods

This was a cross sectional study in which 587 pregnant women with no symptoms and signs of urinary tract infection were recruited from January to March 2019. Mid-stream clean catch urine samples were collected from the women using sterile containers. The urine samples were cultured using standard laboratory methods. The bacterial colonies were identified and antibiotic sensitivity was done using disc diffusion method. Chi squared tests and logistic regression were done to identify factors associated with asymptomatic bacteriuria. A p value < 0.05 was considered statistically significant.

Results

Out of the 587 pregnant women, 22 (3.75%) tested positive for asymptomatic bacteriuria. Women aged 20–24 years were less likely to have ASBP when compared to women aged less than 20 years (AOR = 0.14, 95%CI 0.02–0.95, P = 0.004). The most common isolates in descending order were E. coli (n = 13, 46.4%) and S.aureus (n = 9, 32.1%). Among the gram negative isolates, the highest sensitivity was to gentamycin (82.4%) and imipenem (82.4%). The gram positive isolates were sensitive to gentamycin (90.9%) followed by imipenem (81.8%). All the isolates were resistant to sulphamethoxazole with trimethoprim (100%). Multidrug resistance was 82.4% among gram negative isolates and 72.4% among the gram positive isolates.

Conclusion

There was high resistance to the most commonly used antibiotics. There is need to do urine culture and sensitivity from women with ASBP so as to reduce the associated complications.

Assessment of interventions to attract and retain health workers in rural Zambia: a discrete choice experiment

BACKGROUND

Workforce shortages, particularly in rural areas, limit the delivery of health services in Zambia. Policymakers and researchers co-created this study to identify potential non-monetary employment incentives and assess their cost-effectiveness to attract and retain public sector health workers to the rural areas of Zambia.

METHODS

The study consisted of two key phases: a discrete choice experiment (DCE), preceded by a qualitative component to inform DCE questionnaire development. Firstly, in qualitative interviews with 25 health workers and focus group discussions (FGDs) with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment (DCE) questionnaire. Secondly, this questionnaire, consisting of hypothetical job "choice sets," was presented to 474 practicing health workers and students. A conditional logit regression model was applied to the data from this DCE questionnaire to estimate preferences for various job attributes. Using administrative data, we estimated the cost of implementing potential attraction and retention strategies per health worker year worked.

RESULTS

Although health workers preferred urban jobs to rural jobs (OR 1.39, 95% CI 1.11-1.75), employment incentives influenced health workers' decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job (OR 5.04, 95% CI 4.12-6.18). Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake.

CONCLUSIONS

Non-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages. These results can provide valuable insight into the types of job attributes and incentives that are most likely to be effective in attracting and retaining health workers in rural areas.

Association between internal migration and epidemic dynamics: an analysis of cause-specific mortality in Kenya and South Africa using health and demographic surveillance data

BACKGROUND

Many low- and middle-income countries are facing a double burden of disease with persisting high levels of infectious disease, and an increasing prevalence of non-communicable disease (NCD). Within these settings, complex processes and transitions concerning health and population are underway, altering population dynamics and patterns of disease. Understanding the mechanisms through which changing socioeconomic and environmental contexts may influence health is central to developing appropriate public health policy. Migration, which involves a change in environment and health exposure, is one such mechanism.

METHODS

This study uses Competing Risk Models to examine the relationship between internal migration and premature mortality from AIDS/TB and NCDs. The analysis employs 9 to 14 years of longitudinal data from four Health and Demographic Surveillance Systems (HDSS) of the INDEPTH Network located in Kenya and South Africa (populations ranging from 71 to 223 thousand). The study tests whether the mortality of migrants converges to that of non-migrants over the period of observation, controlling for age, sex and education level.

RESULTS

In all four HDSS, AIDS/TB has a strong influence on overall deaths. However, in all sites the probability of premature death (45q15) due to AIDS/TB is declining in recent periods, having exceeded 0.39 in the South African sites and 0.18 in the Kenyan sites in earlier years. In general, the migration effect presents similar patterns in relation to both AIDS/TB and NCD mortality, and shows a migrant mortality disadvantage with no convergence between migrants and non-migrants over the period of observation. Return migrants to the Agincourt HDSS (South Africa) are on average four times more likely to die of AIDS/TB or NCDs than are non-migrants. In the Africa Health Research Institute (South Africa) female return migrants have approximately twice the risk of dying from AIDS/TB from the year 2004 onwards, while there is a divergence to higher AIDS/TB mortality risk amongst female migrants to the Nairobi HDSS from 2010.

CONCLUSION

Results suggest that structural socioeconomic issues, rather than epidemic dynamics are likely to be associated with differences in mortality risk by migrant status. Interventions aimed at improving recent migrant's access to treatment may mitigate risk.

Inhibition of merozoite invasion and transient de-sequestration by sevuparin in humans with Plasmodium falciparum malaria

SEVERE MALARIA

Even with the best available treatment, the mortality from severe Plasmodium falciparum malaria remains high. Typical features at death are high parasite loads and obstructed micro- vasculature. Infected erythrocytes (IE) containing mature parasites bind to the host receptor heparan sulfate, which is also an important receptor for merozoite invasion. To block merozoite invasion has not previously been proposed as an adjunctive therapeutic approach but it may preclude the early expansion of an infection that else leads to exacerbated sequestration and death.

SEVUPARIN IN PHASE I STUDY

The drug sevuparin was developed from heparin because heparan sulfate and heparin are nearly identical, so the rationale was that sevuparin would act as a decoy receptor during malaria infection. A phase I study was performed in healthy male volunteers and sevuparin was found safe and well tolerated.

SEVUPARIN IN PHASE I/II CLINICAL STUDY

A phase I/II clinical study was performed in which sevuparin was administered via short intravenous infusions to malaria patients with uncomplicated malaria who were also receiving atovaquone/proguanil treatment. This was a Phase I/II, randomized, open label, active control, parallel assignment study. Sevuparin was safe and well tolerated in the malaria patients. The mean relative numbers of ring-stage IEs decreased after a single sevuparin infusion and mature parasite IEs appeared transiently in the circulation. The effects observed on numbers of merozoites and throphozoites in the circulation, were detected already one hour after the first sevuparin injection. Here we report the development of a candidate drug named sevuparin that both blocks merozoite invasion and transiently de-sequesters IE in humans with P. falciparum malaria.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01442168.

A training manual for event history data management using Health and Demographic Surveillance System data

OBJECTIVE

The objective of this research note is to introduce a training manual for event history data management. The manual provides a first comprehensive guide to longitudinal Health and Demographic Surveillance System (HDSS) data management that allows for a step-by-step description of the process of structuring and preparing a dataset for the calculation of demographic rates and event history analysis. The research note provides some background information on the INDEPTH Network, and the iShare data repository and describes the need for a manual to guide users as to how to correctly handle HDSS datasets.

RESULTS

The approach outlined in the manual is flexible and can be applied to other longitudinal data sources. It facilitates the development of standardised longitudinal data management and harmonization of datasets to produce a comparative set of results.

Visual Adaptations for Mate Detection in the Male Carpenter Bee Xylocopa tenuiscapa

Sexual dimorphism in eye structure is attributed to sexual selection in animals that employ vision for locating mates. In many male insects, large eyes and eye regions of higher acuity are believed to facilitate the location of females. Here, we compare various features of male and female eyes in three sympatric carpenter bee species, which include two diurnal species (Xylocopa tenuiscapa and X. leucothorax) as well as a nocturnal species (X. tranquebarica). In X. tenuiscapa, males have larger eyes than females, while in the nocturnal X. tranquebarica, males have slightly smaller eyes and in X. leucothorax, the eyes are of similar size in both sexes. X. tenuiscapa males detect females by perching near nest sites (resource defence) or along fly-ways and other open areas with good visibility. Males of the other two species search for females by patrolling. We postulate that the larger eyes of male X. tenuiscapa are beneficial to their mode of mate detection since perching males may benefit from a larger visual area of high resolution detecting moving stimuli across the sky, and which may be germane to the more social and gregarious nesting behaviour of this species, compared to the other solitary bees. We tested the performance of the eyes of male X. tenuiscapa behaviourally and find that a perching male can detect a flying female at a distance of 20 m, which darkens the visual field of a single ommatidium by just 2%. This, together with the bee's high spatial resolution permits detection of moving stimuli at least as well or even better than achieved by honey bee drones.

Pneumococcal Carriage in Children under Five Years in Uganda-Will Present Pneumococcal Conjugate Vaccines Be Appropriate?

BACKGROUND

Pneumonia is the major cause of death in children globally, with more than 900,000 deaths annually in children under five years of age. Streptococcus pneumoniae causes most deaths, most often in the form of community acquired pneumonia. Pneumococcal conjugate vaccines (PCVs) are currently being implemented in many low-income countries. PCVs decrease vaccine-type pneumococcal carriage, a prerequisite for invasive pneumococcal disease, and thereby affects pneumococcal disease and transmission. In Uganda, PCV was launched in 2014, but baseline data is lacking for pneumococcal serotypes in carriage.

OBJECTIVES

To study pneumococcal nasopharyngeal carriage and serotype distribution in children under 5 years of age prior to PCV introduction in Uganda.

METHODS

Three cross-sectional pneumococcal carriage surveys were conducted in 2008, 2009 and 2011, comprising respectively 150, 587 and 1024 randomly selected children aged less than five years from the Iganga/Mayuge Health and Demographic Surveillance Site. The caretakers were interviewed about illness history of the child and 1723 nasopharyngeal specimens were collected. From these, 927 isolates of S. pneumoniae were serotyped.

RESULTS

Overall, the carriage rate of S. pneumoniae was 56% (957/1723). Pneumococcal carriage was associated with illness on the day of the interview (OR = 1.50, p = 0.04). The most common pneumococcal serotypes were in descending order 19F (16%), 23F (9%), 6A (8%), 29 (7%) and 6B (7%). One percent of the strains were non-typeable. The potential serotype coverage rate for PCV10 was 42% and 54% for PCV13.

CONCLUSION

About half of circulating pneumococcal serotypes in carriage in the Ugandan under-five population studied was covered by available PCVs.

Combining Attractants and Larvicides in Biodegradable Matrices for Sustainable Mosquito Vector Control

Background

There is a global need for cost-effective and environmentally friendly tools for control of mosquitoes and mosquito-borne diseases. One potential way to achieve this is to combine already available tools to gain synergistic effects to reduce vector mosquito populations. Another possible way to improve mosquito control is to extend the active period of a given control agent, enabling less frequent applications and consequently, more efficient and longer lasting vector population suppression.

Methodology/principal findings

We investigated the potential of biodegradable wax emulsions to improve the performance of semiochemical attractants for gravid female culicine vectors of disease, as well as to achieve more effective control of their aquatic larval offspring. As an attractant for gravid females, we selected acetoxy hexadecanolide (AHD), the Culex oviposition pheromone. As toxicant for mosquito larvae, we chose the biological larvicides Bacillus thuringiensis israelensis (Bti) and Bacillus sphaericus (Bs). These attractant and larvicidal agents were incorporated, separately and in combination, into a biodegradable wax emulsion, a commercially available product called SPLAT (Specialized Pheromone & Lure Application Technology) and SPLATbac, which contains 8.33% Bti and 8.33% Bs. Wax emulsions were applied to water surfaces as buoyant pellets of 20 mg each. Dose-mortality analyses of Culex quinquefasciatus Say larvae demonstrated that a single 20 mg pellet of a 10⁻¹ dilution of SPLATbac in a larval tray containing 1 L of water caused 100% mortality of neonate (1^st instar) larvae for at least five weeks after application. Mortality of 3^rd instar larvae remained equally high with SPLATbac dilutions down to 10⁻² for over two weeks post application. Subsequently, AHD was added to SPLAT (emulsion only, without Bs or Bti) to attract gravid females (SPLATahd), or together with biological larvicides to attract ovipositing females and kill emerging larvae (SPLATbacAHD, 10⁻¹ dilution) in both laboratory and semi-field settings. The formulations containing AHD, irrespective of presence of larvicides, were strongly preferred as an oviposition substrate by gravid female mosquitoes over controls for more than two weeks post application. Experiments conducted under semi-field settings (large screened greenhouse, emulating field conditions) confirmed the results obtained in the laboratory. The combination of attractant and larvicidal agents in a single formulation resulted in a substantial increase in larval mosquito mortality when compared to formulations containing the larvicide agents alone.

Conclusions/significance

Collectively, our data demonstrate the potential for the effective use of wax emulsions as slow release matrices for mosquito attractants and control agents. The results indicate that the combination of an oviposition attractant with larvicides could synergize the control of mosquito disease vectors, specifically Cx. quinquefasciatus, a nuisance pest and circumtropical vector of lymphatic filariasis and encephalitis.

Traditionally, a key intervention in mosquito control is the use of insecticides against the adult stage. However, various factors limit the long-term use of these control methods, including the development of insecticide resistance, changes in mosquito biting behaviour, and concerns regarding potential negative impacts of insecticides on the environment. There is therefore a need for alternative management strategies, such as those that target aquatic life stages of mosquitoes. The objective of this study was to investigate the potential of biodegradable wax emulsions such as SPLAT for use in attracting gravid females and control of aquatic stages of culicine vectors. Culex mosquito oviposition pheromone (acetoxy hexadecanolide, AHD) was selected as an attractant, and Bacillus thuringiensis israelensis (Bti) and Bacillus sphaericus (Bs) were used as control agents. Buoyant 20 mg pellets, created by drying SPLAT dollops prior to application, were applied to water surfaces. Dose-mortality analyses of Cx. quinquefasciatus larvae demonstrated that one single pellet caused 100% mortality of first instar larvae for at least five weeks post application. Mortality of 3^rd instar larvae remained equally high even at 10⁻² dilutions for over two weeks post application. In addition, AHD was embedded in SPLAT to either attract gravid females (SPLATahd) or to first attract gravid females to oviposit and then to kill the resulting larval offspring (SPLATbacAHD, 10⁻¹ dilution) in both laboratory and semi-field settings. The wax matrix containing AHD, with or without Bti and Bs, was strongly preferred as an oviposition substrate over controls for over two weeks post application. Both laboratory and semi-field experiments showed a marked increase in larval mortality effects when a semiochemical attractant and larvicides were combined, compared to matrices containing larvicides alone. These findings indicate the potential for using wax emulsions such as SPLAT as a slow release matrix for mosquito attractants and control agents; and that the combination could synergize the control of Cx. quinquefasciatus.

Gender Inequality Prevents Abused Women from Seeking Care Despite Protection Given in Gender-Based Violence Legislation: A Qualitative Study from Rwanda

Objective

Despite its burden on a person’s life, Intimate Partner Violence (IPV) is known to be poorly recognised and managed in most countries and communities. This study aimed to explore health care professionals’ experiences of the health care seeking processes of women exposed to intimate partner violence in Rwanda.

Methods

Six focus group discussions were conducted in three district hospitals and three mental health units in Rwanda. A sample of 43 health care professionals with various professions and length of work experience, who regularly took care of patients subjected to IPV, was selected for focus group discussions. The analysis was performed using qualitative content analysis.

Results

The theme “Gendered norms and values defeat the violence legislation in women’s health care seeking when women are abused” expressed the health care professionals’ experiences of the double-faced situation which women exposed to IPV met in their help seeking process. Positive initiatives to protect women were identified, but the potential for abused women to seek help and support was reduced because of poverty, gender inequality with prevailing strong norms of male superiority, and the tendency to keep abuse as a private family matter.

Conclusion

Legislative measures have been instituted to protect women from abuse. Still many Rwandan women do not benefit from these efforts. The role of the health care services needs to be reinforced as an important and available resource for help and support for abused women but further legislative changes are also needed. Initiatives to further improve gender equality, and institutionalised collaboration between different sectors in society would contribute to protecting women from IPV.