Optimizing Haemophilia Care in Resource-Limited Countries: Current Challenges and Future Prospects

About 75% of persons with hemophilia live in the developing world and do not have access to routine care due to many barriers. There are a lot of challenges associated with hemophilia care in resource-limited settings, ranging from financial to organisational and government commitments. This review discusses some of these challenges and future prospects, while highlighting the important role of the World Federation of Hemophilia in hemophilia patient care. A participative approach involving all stakeholders is key to optimizing care in resource-limited settings.

Hemophilia care in Africa: Status and challenges

Haemophilia care remains challenging especially in resource-limited settings where haemophilia and other non-communicable diseases may not be considered a healthcare priority, in comparison to malaria, HIV/AIDS and other infectious diseases. This article is a review of the evolution in haemophilia care in Africa, with focus on countries with varying degrees of care (Cameroon with budding care; Senegal with more evolved care and Egypt with a more longstanding history of care). The indispensable role of the World Federation of Haemophilia is highlighted in all the contexts of care.

Impact of HIV-1infection on survival in patients with haematological malignancies in Yaoundeé, Cameroon

The impact of HIV-1 infection on the survival of patients with haematological cancers in Yaoundeé, Cameroon, was examined. The prevalence of HIV-1 was 26.2% among 172 patients, predominantly lymphoid malignancies. At the time of analysis, 75% of patients had died giving an incidence rate of 0.05 deaths per year and a median of survival of 15 (6-27) months. However, the hazard ratio for HIV-infected patients to die was not statistically different from that of uninfected patients (1.3, 95% confidence interval: 0.9-2.0).

Blood safety begins with safe donations: update among blood donors in Yaounde, Cameroon

Blood safety continues to be an issue of concern in most countries of the African region. An important contributing factor to blood insecurity is the absence of regular, voluntary and nonremunerated blood donors. An update is provided on blood donors in Yaoundé, Cameroon. Raising the alarm through the dissemination of alarming statistics and continuous sensitization of the community remain strategies for attempting to provide a solution to a long-standing but dangerous problem.

Serological findings amongst first-time blood donors in Yaoundé, Cameroon: is safe donation a reality or a myth?

Blood safety remains an issue of major concern in transfusion medicine in developing countries where national blood transfusion services and policies, appropriate infrastructure, trained personnel and financial resources are lacking. This is aggravated by the predominance of family and replacement, rather than regular benevolent, nonremunerated donors. Thus, in order to identify and encourage healthy, regular and benevolent nonremunerated donors, consenting first-time blood donors in the Yaoundé University Teaching Hospital were screened for human immunodeficiency virus (HIV), hepatitis B surface antigen (HBSAg), hepatitis C virus (HCV), human T-cell lymphotropic virus-I (HTLV-I) and syphilis using standard methods. Of 252 first-time donors recruited, 66 (26.2%) were positive for at least one of the infections screened. There were 7.9% positive for HIV, 10.7% for HBSAg, 4.8% for HCV and 9.1 and 1.6%, respectively, for syphilis and HTLV-I. About 30% of the 66 infected persons had co-infections. HIV-positive donors had a significantly increased risk of being positive for antibodies to syphilis (OR = 7.27; 95% CI = 2.23-23.51; P = 0.0007), not observed for HBV, HCV and HTLV-I. These results suggest that blood transfusion is still very unsafe in this community and that it is imperative that emphasis be laid on donor education. Furthermore, donors with a history of sexually transmitted infections should be totally excluded from all donations.

HIV-1 infection in adults with haematological malignancies in Yaoundé, Cameroon

To determine the association between haematological malignancies and the HIV-1 in Yaoundé, Cameroon, adult patients (> 16 years) followed up in the Haematology Clinics of two major hospitals were screened for the HIV between 1994 and 1999. There were nine haematological malignancies diagnosed among the 172 patients including Non Hodgkin's lymphomas (31.9%); chronic lymhocytic leukaemia (21.5%); chronic myelogeneous leukaemia (18.0%); acute myelogeneous leukaemia (9.9%); acute lymphoblastic leukaemia (7.6%) and multiple myeloma (7.0%). Burkitt's lymphoma, Hodgkin's disease and myelodysplastic syndrome were less frequently diagnosed. Forty-five of all cases (26.2%) had antibodies to the HIV-1 virus, predominantly in patients with Non-Hodgkin's lymphomas (p < 0,001, OR = 5.8, adjusted for age; CI = 2.7 - 12.4). About 19.4% and 11.8% of cases with chronic and acute myelogenous leukaemia respectively were HIV-1 positive. Although B-lineage-derived malignancies are more often associated with the HIV infection, other malignant proliferations of the haematopoietic system may not be coincidental.

Knowledge, attitudes and practices of nursing staff in a rural hospital of Cameroon: how much does the health care provider know about the human immunodeficiency virus/acquired immune deficiency syndrome?

Qualitative and quantitative approaches were used in a rural hospital of Cameroon to assess how much nursing personnel know about and practise in regard to human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and to determine health service factors that influence knowledge, attitudes and practices (KAP). Participants included 107 nursing and laboratory staff and 62 patients with AIDS. Self-administered questionnaires were used for nurses, and close-ended questionnaires were administered to patients with AIDS (as a verification tool for staff responses). Focus group discussions (FGD) held with nurse supervisors evaluated health service factors that influence KAP. Overall, 70.1% of the nurses who responded scored highly in the knowledge section compared to 50.5% in the attitude and practice section. There were several outstanding misconceptions and malpractices about HIV/AIDS. Knowledge, but not attitude, was significantly influenced by the grade of the staff (P< 0.001 and P = 0.17, respectively). Approximately 15% of 62 patients with AIDS indicated that they were attended to with signs of disgust and/or hatred. The major health service factors thought to influence KAP, confirmed by many in all the FGD, included: the lack of adequate information; the lack of commitment to alter attitudes and practices; the lack of in-service promotions; and the ongoing fear of becoming infected with the virus through caring for patients with AIDS. Low income also seemed to have an influence on KAP. Therefore, it is imperative that ongoing education programmes are provided for nurses to enable them to meet the needs of the increasing HIV prevalence in our community. Information, education and communication, and compliance with international working norms, remain essential tools in the control of HIV/AIDS spread in our hospital settings.

HLA-DRB1, -DQA1, -DQB1 and DPB1 susceptibility alleles in Cameroonian type 1 diabetes patients and controls

It is known that certain combinations of alleles within the human leucocyte antigen (HLA) complex are associated with susceptibility or resistance to type 1 diabetes. Variable associations of DR and DQ with type 1 diabetes are documented in Caucasians but rarely in African populations; however, the role of HLA-DP genes in type 1 diabetes remains uncertain. In order to investigate the HLA class II associations with type 1 diabetes in Cameroonians, we used sequence-specific oligonucleotide probing (SSOP) to identify DRB1, DQA1, DQB1 and DPB1 alleles in 10 unrelated C-peptide negative patients with type 1 diabetes and 90 controls from a homogeneous population of rural Cameroon. We found a significantly higher frequency of the alleles DRB1*03 (chi2 = 17.9; P = 0.001), DRB1*1301 (chi2 = 37.4; P < 0.0001), DQA1*0301 (chi2 = 18.5; P = 0.001) and DQB1*0201 (chi2 = 37.4; P < 0.001) in diabetes patients compared to the control group. The most frequent alleles in the control population were DQA1*01, DQB1*0602 and DRB1*15. The DRB1*04 allele was not significantly associated with type I diabetes in our study population. We observed no significant difference between patients and controls in DPB1 allele frequency. In conclusion, the data in Cameroonian diabetes patients suggest the existence of HLA class II predisposing and specific protective markers, but do not support previous reports of a primary association between HLA-DP polymorphism and development of type I diabetes.

Model for assessment of endothelial cell function and viability using the MTT dye test and [3H]

OBJECTIVES

To establish a reproducible in vitro model for evaluating endothelial cell function in clinical disease states.

DESIGN

A prospective study of human umbilical vein endothelial cells (HUVEC) isolated and cultured.

SETTING

Department of Haematology, University of Yaounde I, Cameroon and Department of Medicine University of Newcastle-upon-Tyne, England.

RESULTS

The optimum initial cell seeding concentration, for maximal conversion of the formazan dye was 40 x 10(3) cells/well, after 24 hours incubation. At concentrations above 40 x 103 cells/well some inhibition of dye conversion occurred. The conversion of formazan dye was directly proportional to cell numbers for the first 48 hours only, at all cell concentrations. Thereafter, cell metabolism appeared to be inhibited. Third passage endothelial cells (ECs) were exposed to a range of lipopolysaccharide (LPS) concentrations for one and 24 hours, prior to performing the MTT dye test. Dye conversion was observed after one hour at even the lowest concentration of LPS (0.1 microgram/ml), to 49.9% +/- 5.6% of unperturbed control EC, with 10 x 10(3) initial seeding numbers. After 24 hours perturbation a small but statistically significant further inhibition was observed. [3H] thymidine incorporation studies indicated that the lowest LPS concentration tested (0.1 microgram/ml) had a stimulatory effect on DNA synthesis at the higher cell concentration (20 x 10(3) cells/well). In the range of 1 to 100 micrograms/ml of the LPS tested, there was increased DNA synthesis at all cell numbers.

CONCLUSION

The model may be used to monitor the effects of other agents which are known to, or could be associated with, alterations in endothelial cell function and will serve in mimicking clinical situations including hyper coagulable states.

Reduced insulin secretion in offspring of African type 2 diabetic parents

OBJECTIVE

To determine the early biochemical predictors of increased susceptibility to develop diabetes in offspring of African type 2 diabetic parents.

RESEARCH DESIGN AND METHODS

A total of 69 offspring (case subjects) of 26 families in Cameroon with at least one type 2 diabetic parent were studied, and 62 offspring (control subjects) from 25 families in Cameroon with no parent with type 2 diabetes underwent an oral glucose tolerance test. Early insulin secretion was calculated using the ratio of the 0- to 30-min incremental insulin values to the 0- to 30-min incremental glucose. Anthropometric parameters were also measured.

RESULTS

Of the case subjects, 23% were glucose intolerant (4% with diabetes and 19% with impaired glucose tolerance [IGT]) compared with 6.5% (all with IGT) of control subjects (P = 0.02). There was also an increasing prevalence of glucose intolerance, especially IGT with increasing number of glucose-intolerant parents. Fasting serum insulin levels were not different in the two groups; however, at 30 min, the case subjects had lower insulin levels than the control subjects (P < 0.006). Case subjects with IGT had lower 30-min insulin concentration, early insulin secretion, and 2-h insulin levels than those with normal glucose tolerance (NGT) (F = 4.1, P < 0.05; F = 4.1, P < 0.04; and F = 5.1, P < 0.03, respectively). Furthermore, case subjects with NGT and IGT had lower early insulin secretion than control subjects (F = 4. 1, P < 0.03). These differences remained after adjustment for BMI and regardless of the status of parental diabetes. Two-hour insulin concentration showed a positive association (odds ratio = 0.95 CI 0.90-0.99, P = 0.039) with IGT in the case subjects.

CONCLUSIONS

Diabetes and IGT are more prevalent in the offspring of African type 2 diabetic parents, and this may be due to an underlying degree of beta-cell impairment marked by reduced early-phase insulin secretion.