Case identification, retention and blood pressure control in Kenya

BACKGROUND

Prevalence of hypertension in Africa is rising but it remains underdiagnosed and poorly controlled. In Kenya, only 22% of individuals known to have hypertension were on treatment, and only 51.7% were controlled. This study will assess screening outcomes, retention and blood pressure (BP) control of a hypertension programme in Kenya.

DESIGN

This was a retrospective cohort study using data routinely collected between 2015 and 2018. All patients aged >18 years screened and treated in the programme were included.

RESULTS

Of 663,028 screening encounters, 70.4% were female; the median age was 34 years. Overall, 19% of the study population, mainly males and older persons, had high BP higher rates. Of 66,981 patients started on treatment, the majority were females (71.2%); the median age was 55 years. Only 12% of patients were reported as having been retained after 12 months, and 48.6% of patients on treatment 10.5-13.5 months after enrolment had controlled BP. Older age and treatment at primary care level were associated with better retention and females had better BP control.

CONCLUSIONS

The programme screened primarily females and younger individuals at lower risk. Retention was poor and close to half of patients retained had controlled BP. Hypertension programmes should target high-risk individuals, decentralise treatment, incorporate retention strategies and improve longitudinal data management.

Short-course treatment outcomes and adverse events in adults and children-adolescents with MDR-TB in Niger

<sec id="st1"> <title>SETTING</title> Niger National Tuberculosis Programme. </sec> <sec id="st2"> <title>OBJECTIVE</title> To describe the outcomes and adverse events (AEs) in a cohort of adults, children and adolescents with multidrug-resistant tuberculosis (MDR-TB) who were treated with the 'short-course regimen'. </sec> <sec id="st3"> <title>DESIGN</title> The regimen comprised an intensive phase of 4-6 months with kanamycin, medium-high dose of isoniazid and prothionamide, and high doses of gatifloxacin, clofazimine, ethambutol and pyrazinamide throughout. Sixty-five patients were treated with a regimen of 12-14 months and 55 patients with a regimen of 9-11 months. </sec> <sec id="st4"> <title>RESULTS</title> Of the 120 patients evaluated, 110 (92%) were adults (median age 31 years) and 10 (8%) were children or adolescents (median age 17 years). The treatment success rate was respectively 88% and 83% with the 9-month regimen, and 90% and 75% with the 12-month regimen in adults and children/adolescents. Initial resistance to ethambutol and prothionamide did not affect treatment success rates but resistance to fluoroquinolones did, although this was not statistically significant. Vomiting was the most frequently encountered AE, followed by ototoxicity and hepatotoxicity. AEs experienced were mild or moderate in severity in most patients, and did not lead to treatment interruption. </sec> <sec id="st5"> <title>CONCLUSION</title> These results confirm the programmatic effectiveness and tolerability of the shorter regimen in second-line drug-naïve patients. </sec>.

Multi-level Determinants of Clinic Attendance and Antiretroviral Treatment Adherence Among Fishermen Living with HIV/AIDS in Communities on Lake Victoria, Uganda

This cross-sectional study assessed determinants of HIV clinic appointment attendance and antiretroviral treatment (ART) adherence among 300 male fisherfolk on ART in Wakiso District, Uganda. Multi-level factors associated with missed HIV clinic visits included those at the individual (age, AOR = 0.98, 95% CI 0.97-0.99), interpersonal (being single/separated from partner, AOR: 1.25, 95% CI 1.01-1.54), normative (anticipated HIV stigma, AOR: 1.55, 95% CI 1.05-2.29) and physical/built environment-level (travel time to the HIV clinic, AOR: 1.11, 95% CI 1.02-1.20; structural-barriers to ART adherence, AOR: 1.27, 95% CI 1.04-1.56; accessing care on a landing site vs. an island, AOR: 1.35, 95% CI 1.08-1.67). Factors associated with ART non-adherence included those at the individual (age, β: - 0.01, η2 = 0.03; monthly income, β: - 0.01, η2 = 0.02) and normative levels (anticipated HIV stigma, β: 0.10, η2 = 0.02; enacted HIV stigma, β: 0.11, η2 = 0.02). Differentiated models of HIV care that integrate stigma reduction and social support, and reduce the number of clinic visits needed, should be explored in this setting to reduce multi-level barriers to accessing HIV care and ART adherence.

Moving towards malaria elimination: trends and attributes of cases in Kavango region, Namibia, 2010-2014

Setting: Kavango, a 'moderate' transmission risk region located in north-eastern Namibia, borders Angola, a country with higher malaria transmission levels. Objective: To determine 1) the trends in malaria incidence between 2010 and 2014 in Kavango, 2) the socio-demographic and clinical characteristics of confirmed cases in 2014, and 3) associated risk factors of cases classified as imported. Design: This was a retrospective study of malaria case investigation forms conducted in all 52 public health facilities in 2014. Incidence was derived from aggregate routine surveillance data from the Health Information System (HIS). Results: During the 5-year study, incidence fell from 53.6 to 3.6 cases per 1000 population, then increased again to 47.3/1000. Fifty-five per cent of cases were males, and 49% were aged between 5 and 17 years. Of the 2014 cases, 23% were imported, and were associated with higher odds of severe malaria (adjusted odds ratio [aOR] 1.8; 95%CI 1.01-3.29), not having long-lasting insecticide treated nets (aOR 2.1, 95%CI, 1.3-3.4) and not receiving insecticide residual spraying (aOR 3.2, 95%CI, 2.1-5.1). Conclusion: Sporadic outbreaks in the 5-year period posed a threat to malaria elimination. Better targeting of vector control interventions, strong cross-border collaboration and robust health promotion will be key to achieving malaria elimination.

Is there a correlation between malaria incidence and IRS coverage in western Zambezi region, Namibia?

Setting: A comparison of routine Namibia National Malaria Programme data (reported) vs. household survey data (administrative) on indoor residual spraying (IRS) in western Zambezi region, Namibia, for the 2014-2015 malaria season. Objectives: To determine 1) IRS coverage (administrative and reported), 2) its effect on malaria incidence, and 3) reasons for non-uptake of IRS in western Zambezi region, Namibia, for the 2014-2015 malaria season. Design: This was a descriptive study. Results: IRS coverage in western Zambezi region was low, ranging from 42.3% to 52.2% for administrative coverage vs. 45.9-66.7% for reported coverage. There was no significant correlation between IRS coverage and malaria incidence for this region (r = -0.45, P = 0.22). The main reasons for households not being sprayed were that residents were not at home during spraying times or that spray operators did not visit the households. Conclusions: IRS coverage in western Zambezi region, Namibia, was low during the 2014-2015 malaria season because of poor community engagement and awareness of times for spray operations within communities. Higher IRS coverage could be achieved through improved community engagement. Better targeting of the highest risk areas by the use of malaria surveillance will be required to mitigate malaria transmission.

High mortality in tuberculosis patients despite HIV interventions in Swaziland

SETTING

All health facilities providing tuberculosis (TB) care in Swaziland.

OBJECTIVE

To describe the impact of human immunodeficiency virus (HIV) interventions on the trend of TB treatment outcomes during 2010-2013 in Swaziland; and to describe the evolution in TB case notification, the uptake of HIV testing, antiretroviral therapy (ART) and cotrimoxazole preventive therapy (CPT), and the proportion of TB-HIV co-infected patients with adverse treatment outcomes, including mortality, loss to follow-up and treatment failure.

DESIGN

A retrospective descriptive study using aggregated national TB programme data.

RESULTS

Between 2010 and 2013, TB case notifications in Swaziland decreased by 40%, HIV testing increased from 86% to 96%, CPT uptake increased from 93% to 99% and ART uptake among TB patients increased from 35% to 75%. The TB-HIV co-infection rate remained around 70% and the proportion of TB-HIV cases with adverse outcomes decreased from 36% to 30%. Mortality remained high, at 14-16%, over the study period, and anti-tuberculosis treatment failure rates were stable over time (<5%).

CONCLUSION

Despite high CPT and ART uptake in TB-HIV patients, mortality remained high. Further studies are required to better define high-risk patient groups, understand the reasons for death and design appropriate interventions.

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

Bringing care to the community: expanding access to health care in rural Malawi through mobile health clinics

SETTING

Malawi has chronic shortages of health workers, high burdens of human immunodeficiency virus (HIV) infection and malaria and a predominately rural population. Mobile health clinics (MHCs) could provide primary health care for adults and children in hard-to-reach areas.

OBJECTIVES

To determine the feasibility, volume, and types of services provided by three MHCs from 2011 to 2013 in Mulanje District, Malawi.

DESIGN

Cross-sectional retrospective study.

RESULTS

The MHCs conducted 309 492 visits for primary health care, and in 2013 services operated on 99% of planned days. Despite an improvement in service provision, overall patient visits declined over the study period. Malaria and respiratory and gastro-intestinal conditions constituted 60% of visits. Females (n = 11 543) significantly outnumbered males (n = 2481) tested for HIV, yet males tested HIV-positive (27%) more often than females (14%). Malaria accounted for 26 421 (35%) visits for children aged <5 years, with a significant increase in the rainy season. Implementation of rapid diagnostic testing was associated with a decline in numbers treated for malaria. Antibiotic stockouts at government clinics were associated with increased MHC visits.

CONCLUSION

MHCs can routinely provide primary health care for adults and children living in rural Malawi and complement fixed clinics. Moving from a complementary role to integration within the government health system remains a challenge.

Antenatal care and pregnancy outcomes in a safe motherhood health voucher system in rural Kenya, 2007-2013

SETTING

A rural private health facility, Ruby Medical Centre (RMC), participating in a safe motherhood health voucher system for poor women in Kiambu County, Kenya.

OBJECTIVES

Between 2007 and 2013, to determine 1) the number of women who delivered at the RMC, their characteristics and pregnancy-related outcomes, and 2) the number of women who received an incomplete antenatal care (ANC) package and associated factors.

DESIGN

Retrospective cross-sectional study using routine programme data.

RESULTS

During the study period, 2635 women delivered at the RMC: 50% were aged 16-24 years, 60% transferred in from other facilities and 59% started ANC in the third trimester of pregnancy. Of the 2635 women, 1793 (68%) received an incomplete ANC package: 347 (13%) missed essential blood tests, 312 (12%) missed the tetanus toxoid immunisation and 1672 (65%) had fewer than four visits. Presenting late and starting ANC elsewhere were associated with an incomplete package. One pregnancy-related mortality occurred; the stillbirth rate was 10 per 1000 births.

CONCLUSION

This first assessment of the health voucher system in rural Kenya showed problems in ANC quality. Despite favourable pregnancy-related outcomes, increased efforts should be made to ensure earlier presentation of pregnant women, comprehensive ANC, and more consistent and accurate monitoring of reproductive indicators and interventions.

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals, Uganda

SETTING

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases.

OBJECTIVE

To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes.

DESIGN

A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010.

RESULTS

The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73).

CONCLUSION

Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.

Preventable but neglected: rickets in an informal settlement, Nairobi, Kenya

SETTING

The primary care clinics of Médecins Sans Frontières within the informal settlement of Kibera, Nairobi, Kenya.

OBJECTIVE

To describe the demographic and clinical characteristics of children clinically diagnosed with rickets from September 2012 to October 2013.

DESIGN

Descriptive retrospective case review of diagnosis and treatment course with vitamin D and calcium using routine programme data.

RESULTS

Of the 82 children who met the clinical diagnosis of rickets, 57% were male, with a median age of 12 months and 14 months for females. Children with rickets were found to have ⩽3 hours/week sunlight exposure for 71% of the children and malnutrition in 39%. Clinical findings on presentation revealed gross motor developmental delays in 44%. The loss to follow-up rate during treatment was 40%.

CONCLUSIONS

This study found that rickets is a common clinical presentation among children living in the informal settlement of Kibera and that there are likely multiple factors within that environment contributing to this condition. As rickets is a simply and inexpensively preventable non-communicable disease, we suggest that routine vitamin D supplementation be formally recommended by the World Health Organization for well-child care in Africa, especially in the contexts of informal settlements.

Prevalence and incidence of cervical intra-epithelial neoplasia among female sex workers in Korogocho, Kenya

SETTING

Sex Workers Outreach Programme Clinic, Korogocho, Nairobi, Kenya.

OBJECTIVE

In a cohort of sex workers, to determine 1) the prevalence of cervical intra-epithelial neoplasia (CIN) and its association with human immunodeficiency virus-1 (HIV-1) infection, and 2) the incidence rate of CIN during the 3-year follow-up from December 2009 to December 2012.

DESIGN

Prospective nested cohort study.

RESULTS

Of the 350 women enrolled, the median age was 29 years (range 18-49); 84 (24%) were HIV-1-infected. At enrollment, 54 (15%) had an abnormal cytology, 39 (11%) had low-grade intra-epithelial lesions (LSIL) and 15 (4%) high-grade intraepithelial lesions (HSIL). HIV-1-infected women were 2.7 times (95%CI 1.7-4.4) more likely to have CIN than non-HIV-1-infected women. Among HIV-1-infected women, the prevalence of LSIL and HSIL was 2.5 times (95%CI 1.2-5.1) and seven times (95%CI 2.3-23.3) greater than among non-HIV-infected women. During the follow-up period, 39 (11%) women had incident CIN (6.6/100 person years [py]), with no difference by HIV status, i.e., respectively 7.9/100 py and 6.3/100 py in HIV-1-infected and non-HIV-1-infected women.

CONCLUSION

The prevalence and incidence of CIN among HIV-1-infected sex workers was high; early, regular screening and follow-up of this life-threatening condition is therefore recommended.

Does the 65 cm height cut-off as age proxy exclude children eligible for nutritional assessment in Bangladesh?

SETTING

Kamrangirchar slum, Dhaka, Bangladesh.

OBJECTIVE

During nutritional surveys and in circumstances when it is difficult to ascertain children's age, length/height cut-offs are used as proxy for age to sample children aged 6-59 months. In a context of prevalent stunting, using data from primary health care centres where age and height parameters were well-recorded, we assessed the proportion of children aged between 6 and 59 months who would be excluded from nutritional assessment using a height cut-off of 65 cm as a proxy for age ≥6 months.

DESIGN

This was a secondary data analysis of primary health centre data.

RESULTS

A total of 2060 children were included in the analysis, with a median age of 24 months and a median height of 78 cm (SD 12.1, range 50-109 cm). There were 240 (12%, 95%CI 10-13) children aged between 6 and 29 months, with a height <65 cm. The majority (59%) of these children were females; 97.5% were aged 6-17 months.

CONCLUSION

In an urban slum setting in Bangladesh, the use of the current height cut-off as a proxy for age excludes vulnerable children from nutritional assessment and could also lead to underestimation of the prevalence of malnutrition in nutritional surveys.

Antiretroviral treatment uptake and attrition among HIV-positive patients with tuberculosis in Kibera, Kenya

Using data of human immunodeficiency virus-positive patients with tuberculosis from three primary care clinics in Kibera slums, Nairobi, Kenya, we report on the proportion that started antiretroviral treatment (ART) and attrition (deaths, lost to follow-up and stopped treatment) before and while on ART. Of 427 ART eligible patients, enrolled between January 2004 and December 2008, 70% started ART, 19% were lost to attrition and 11% had not initiated ART. Of those who started ART, 14% were lost to attrition, making a cumulative pre-ART and ART attrition of 33%. ART uptake among patients with TB was relatively good, but programme attrition was high and needs urgent addressing.

Provider-initiated HIV testing and counselling for TB patients and suspects in Nairobi, Kenya

SETTING

Integrated tuberculosis (TB) and human immunodeficiency virus (HIV) services in a resource-constrained setting.

OBJECTIVE

Pilot provider-initiated HIV testing and counselling (PITC) for TB patients and suspects.

DESIGN

Through partnerships, resources were mobilised to establish and support services. After community sensitisation and staff training, PITC was introduced to TB patients and then to TB suspects from December 2003 to December 2005.

RESULTS

Of 5457 TB suspects who received PITC, 89% underwent HIV testing. Although not statistically significant, TB suspects with TB disease had an HIV prevalence of 61% compared to 63% for those without. Of the 614 suspects who declined HIV testing, 402 (65%) had TB disease. Of 2283 patients referred for cotrimoxazole prophylaxis, 1951 (86%) were enrolled, and of 1727 patients assessed for antiretroviral treatment (ART), 1618 (94%) were eligible and 1441 (83%) started treatment.

CONCLUSIONS

PITC represents a paradigm shift and is feasible and acceptable to TB patients and TB suspects. Clear directives are nevertheless required to change practice. When offered to TB suspects, PITC identifies large numbers of persons requiring HIV care. Community sensitisation, staff training, multitasking and access to HIV care contributed to a high acceptance of HIV testing. Kenya is using this experience to inform national response and advocate wide PITC implementation in settings faced with the TB-HIV epidemic.