Clinical and equipment-related factors associated with the adequate peripheral blood stem cell collection in autologous transplant at a tertiary cancer center in Kerala - A retrospective cohort study

BACKGROUND

PBSC collection using apheresis is the preferred source of hematopoietic stem cells transplantation. However, apheresis procedures fail to harvest adequate CD34 yield in 5 to 40% of patients during the first collection. Therefore, this study aimed to study both the clinical- and equipmentrelated factors influencing CD34 yield among the autologous patients and to compare the collection efficiency of two apheresis equipments(Haemonetics MCS+ and Terumo Spectra Optia).

METHODS

Retrospective analysis of 69 patients underwent PBSC collection from 2015 to 2018. Frequency, clinical- and equipment-related factors responsible for adequate CD34+ cells (≥2 x106 cells/kg) yield during the first collection was studied. Factors such as collection efficiency, percentage platelet loss and percentage hemoglobin loss were considered to compare the two apheresis system.

RESULTS

Two-third (72%) patients of the study population had adequate CD34 stem cells yield during the first collection. Factors such as exposure to lenalidomide-based pretreatment regimen, peripheral blood WBC count and CD34 count are associated with the adequate CD34 yield. Optia had a slightly better collection efficiency than MCS+ (50 and 44; p=0.37). Optia had lower product volume (237 vs 298 ml) and lesser procedure duration (277 vs 360 min), whereas the median Hb loss (3.0% and 2.3%) and mean platelet loss (49% and 34%) were higher with MCS.

CONCLUSION

This study infers that the collection efficiency of both the equipments in collecting CD34 stem cells was similar. However, during PBSC collection, procedures using Optia can be preferred to MCS+ on the patients with risk of anemia and thrombocytopenia.

Tuberculosis retreatment outcomes and associated factors: a mixed-methods study from Puducherry, India

Setting: Four Tuberculosis (TB) Units in the Union Territory of Puducherry in India. Objectives: To identify factors associated with unfavourable outcomes among retreatment TB cases in Puducherry. Design: The study had a mixed-methods design in which routinely reported TB data from retreatment TB cases registered during 2014 and 2015 were used for the quantitative part; the qualitative phase comprised interviews and focus group discussions with health care providers. Results: Among the 392 retreatment cases, 297 (75.8%) had favourable outcomes. Outcome for previous treatment such as loss to follow-up (LTFU) (adjusted relative risk [aRR] 1.6, 95%CI 1.1-2.4, P = 0.001), treatment failure (aRR 1.7, 95%CI 1.04-2.8, P = 0.03) and pre-treatment weight <40 kg (aRR 1.8, 95%CI 1.3-2.5, P = 0.001) had increased risk for unfavourable outcomes. Health care providers reported that alcoholism, lack of family support, job-related issues and lack of access to trained staff for injections were some of the reasons for unfavourable outcomes. Providing incentives, nutritional supplements and early retrieval of the LTFU cases were some of the suggestions to reduce unfavourable outcomes. Conclusion: Outcome of previous treatment and low pre-treatment weight of the patient affected retreatment outcomes. Health professionals and workers highlighted social and health system-related factors. Commitment at all levels on the part of health care providers and addressing their concerns can improve retreatment outcomes.

Why are HIV-infected people not started on antiretroviral therapy? A mixed-methods study from Gujarat, India

Setting: Five purposively selected antiretroviral therapy (ART) centres in Gujarat, India. Objectives: To assess the proportion of ART-eligible people living with the human immunodeficiency virus (PLHIV) who were not initiated on ART within 2 months of being recorded as eligible, to identify factors associated with non-initiation and to explore reasons from the provider's perspective. Design: We used a mixed-methods design (triangulation) of 1) a quantitative phase involving record reviews and cohort analysis (Poisson regression) of PLHIV registered during April 2014-March 2015, and 2) a qualitative phase involving one-to-one interviews with 25 providers. Results: Of 2079 ART-eligible PLHIV, 339 (16%) were not started on ART within 2 months. PLHIV with CD4 counts of <350 cells/μl and patients who were labourers, hospitalised, bedridden or registered with certain ART centres were more likely not to be initiated on ART. Qualitative results were categorised into two broad themes: government health system- and patient-related challenges, which validated and complemented the quantitative findings. Conclusion: Several patient subgroups at greater risk of ART non-initiation were identified, along with reasons for risk; this has important programme implications for achieving the UNAIDS 90-90-90 goal, and particularly the second 90 component of having 90% of diagnosed PLHIV start ART.

Life goes on: the resilience of maternal primary care during the Ebola outbreak in rural Sierra Leone

Setting: All 100 health facilities providing maternal services in Moyamba, Sierra Leone, a rural district that experienced a smaller Ebola outbreak than other areas. Objective: To compare trends in antenatal care (the first and fourth visit [ANC1 and ANC4]), delivery, and postnatal care (PNC1) service utilisation before, during and after the Ebola outbreak (2014-2016). Design: Cross-sectional study using secondary programme data. Results: A total of 211 Ebola cases occurred in Moyamba District. The mean number of monthly ANC visits remained stable over time, except for the subset of care provided via outreach visits where, compared with before the outbreak (n = 390), ANC1 visits declined during (n = 331, P = 0.002) and after the outbreak (n = 342, P = 0.03). Most (>97%) deliveries occurred in health facilities, assisted by maternal and child health aides (>80%). During the outbreak, the mean number of community-based deliveries per month declined from 31 to 21 (P = 0.03), and the mean number of deliveries performed by midwives increased from 49 to 78 (P < 0.001) compared with before the outbreak. Before, during and after Ebola, there was no significant change in the mean number of live births (respectively n = 1134, n = 1110, n = 1162), maternal PNC1 (respectively n = 1110, n = 1105, n = 1165) or neonatal PNC1 (respectively n = 1028, n = 1050, n = 1085). Conclusion: In a rural district less affected by Ebola transmission than other areas, utilisation of maternal primary care remained robust, despite the outbreak.

Infection prevention and control in health facilities in post-Ebola Liberia: don't forget the private sector!

Setting: Recognising the importance of infection prevention and control (IPC), a minimum standards tool (MST) was developed in Liberia to guide the safe (re-) opening and provision of care in health facilities. Objectives: To analyse the implementation of specific IPC measures after the 2014 Ebola virus outbreak between June 2015 and May 2016, and to compare the relative improvements in IPC between the public and private sectors. Design: A retrospective comparative cohort study. Results: We evaluated 723 (94%) of the 769 health facilities in Liberia. Of these, 437 (60%) were public and 286 (40%) were private. There was an overall improvement in the MST scores from a median of 13 to 14 out of a maximum possible score of 16. While improvements were observed in all aspects of IPC in both public and private health facilities, IPC implementation was systematically higher in public facilities. Conclusions: We demonstrate the feasibility of monitoring IPC implementation using the MST checklist in post-Ebola Liberia. Our study shows that improvements were made in key aspects of IPC after 1 year of evaluations and tailored recommendations. We also highlight the need to increase the focus on the private sector to achieve further improvements in IPC.

Effects of the 2014 Ebola outbreak on antenatal care and delivery outcomes in Liberia: a nationwide analysis

Setting: All health facilities, public and private, in Liberia, West Africa. Objectives: To determine access to antenatal care (ANC), deliveries and their outcomes before, during and after the 2014-2015 Ebola outbreak. Design: This was a descriptive cross-sectional study. Result: During the Ebola outbreak in Liberia, overall monthly reporting from health facilities plunged by 43%. Access to ANC declined by 50% and reported deliveries fell by one third during the outbreak. Reported deliveries by skilled attendants and Caesarian section declined by respectively 32% and 60%. Facility-based deliveries dropped by 35% and reported community deliveries fell by 47%. There was an overall decline in reported stillbirths, maternal and neonatal deaths, by 50%, during the outbreak. ANC, reported deliveries and related outcomes returned to pre-outbreak levels within one year following the outbreak. Conclusion: The Liberian health system was considerably weakened during the Ebola outbreak and had difficulties providing basic maternal health services. In the light of the major reporting gaps during the Ebola period, and the reduced use of health facilities for maternal care, these findings highlight the need for measures to avoid such disruptions during future outbreaks.