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Using Criteria-Based Audit to Improve the Management of Postpartum Haemorrhage in a University Hospital in Eastern Ethiopia: A Before and After Study
Get PDFObjectives: Postpartum haemorrhage, an excessive bleeding after childbirth, remains a leading cause of maternal mortality in low-resource settings. Improving the quality of postpartum haemorrhage care using audit and embedded quality improvement is essential for addressing this. A criteria-based audit, an objective, systematic and critical analysis of the quality of health care against a set of criteria, is essential for identifying appropriateness of care and areas for improvement in postpartum haemorrhage management. The aim of this study was to audit management of postpartum haemorrhage as quality assessment for postpartum haemorrhage care in a tertiary university hospital in eastern Ethiopia. Methods: In 2023, we repeated the criteria-based audit cycle conducted in 2019 to re-evaluate management of postpartum haemorrhage using the same previously co-created eight audit criteria. Two midwives and one consultant obstetrician independently reviewed each woman's medical records to assess whether a criterion was met or not. Findings were compared with the 2019 reports using a chi-square test and discussed with birth attendants and administrators of the hospital to identify underlying factors and areas for improvement in postpartum haemorrhage care. Results: Of 55 medical records reviewed, fulfilment of the audit criteria ranged from 24% (13/55) for fluid input and output monitoring to 100% (55/55) for documenting woman's history and general clinical conditions at admission, and haemoglobin measurement. Compared with the previous audit, where only 6.7% (3/45) women met all the audit criteria, there was substantial increase in proportion in the current audit as 22% (12/55) cases met all the criteria (p = 0.03). Lack of template for a postpartum haemorrhage management, refresher training, postpartum haemorrhage emergency kit, adherence to postpartum haemorrhage management guideline and adequate blood for transfusion were identified as major barriers to providing optimal postpartum haemorrhage care. Conclusions: Just over one in five women met the local audit criteria for postpartum haemorrhage management, and major barriers to providing the best possible care persist. These results highlights the need to develop a postpartum haemorrhage management template, availing blood for transfusion, providing low-dose high frequency (refresher) training and drills for staff, and enhancing documentation and record keeping in the hospital for improving quality of postpartum haemorrhage management to stop preventable deaths and sequelae from postpartum haemorrhage.</p
Microbiota diversity of Anopheles gambiae in Bankeng, southern Cameroon, and its association with Plasmodium falciparum infection
Get PDFMalaria control requires the coordination of different strategies due to the lack of an effective vaccine and the emerging resistance of parasites to drugs and of vectors to insecticides. Therefore, efficient and environmentally safe alternative control strategies are still needed. In this study, we explored the composition of microbiota of the Anopheles gambiae and its variability in the presence of natural Plasmodium infection during the wet and dry seasons, in order to determine their potential as a novel vector control-based approach to fight malaria. An entomological survey of a collection of An. gambiae was conducted in Bankeng. Using 16S ribosomal RNA amplicon-based sequencing, we investigated the bacterial microbiota of mosquitoes naturally infected or uninfected with Plasmodium falciparum. A total of 120 mosquitoes were selected randomly corresponding to 60 mosquitoes per infection status. Overall, 99 bacterial taxa were detected across all the samples, with 97 of these shared between uninfected and infected. A total of two were unique to uninfected (Acetobacteraceae, Enterococcus), while no bacteria were unique to infected mosquitoes. However, there were significant differences in bacterial composition between both groups. Additionally, differential abundance revealed notable variations in microbiota composition, with 14 bacterial genera more abundant in uninfected mosquitoes and only two bacterial genera more abundant in the infected mosquitoes. Observed amplicon sequence variants and Shannon indices revealed a significant difference in bacterial diversity between infected (positive) and uninfected (negative) An. gambiae with higher diversity observed in negative samples during the wet season and in positive samples during the dry season. These findings highlight potential associations between certain bacterial taxa and infection status, suggesting they may be linked to susceptibility or resistance, although causality cannot be determined from this study. Ultimately, this baseline information provides a foundation for studies on the functions and interactions of the microbiota in natural populations of Anopheles gambiae and their susceptibility to natural Plasmodium infection.IMPORTANCEMalaria control faces challenges due to the absence of an effective vaccine and growing resistance to drugs and insecticides, highlighting the need for alternative strategies. This study investigates the microbiota composition of Anopheles gambiae mosquitoes in Bankeng, Cameroon, and its association with natural Plasmodium falciparum infection. Using 16S rRNA amplicon sequencing, the bacterial communities of 120 mosquitoes-60 infected and 60 uninfected-were analyzed. A total of 99 bacterial taxa were identified, with 97 shared between both groups. Only two taxa (Acetobacteraceae and Enterococcus) were exclusive to uninfected mosquitoes, and none were unique to the infected group. Significant differences in microbiota composition were observed: 14 bacterial genera were more abundant in uninfected mosquitoes, while only two were enriched in infected ones. These findings suggest that specific bacteria may influence susceptibility to Plasmodium infection. This study provides foundational knowledge for exploring microbiota-based or paratransgenic strategies in malaria vector control.</p
Perceptions of integrating cervical cancer screening with HIV and sexual and reproductive health services: results from serial multiple methods studies among health workers and women in Zimbabwe
Get PDFBackground: Cervical cancer screening among Zimbabwean women is suboptimal. Integrating cervical cancer screening with HIV and sexual and reproductive health services can improve uptake. To inform optimisation of integrated models, we explored evolution of women’s and health worker views on integration and cervical cancer screening. Methods: Over three phases between Nov-2013 and Mar-2016, we collected serial multiple methods data from female attendees and health workers at four clinics providing integrated cervical cancer screening and HIV and sexual/reproductive health services. Using program data, we examined trends in uptake of cervical cancer screening. Results: Between 2013 and 2016, 38,342 women were screened for cervical cancer at three clinics. Program data showed increasing trends in uptake, capping at clinic capacity. Qualitative studies showed that clinic attendees and health workers viewed integration positively across phases because: (i) information on cervical cancer screening was easily disseminated, leading to improved uptake; (ii) co-location of services was convenient. As knowledge increased, demand exceeded supply, requiring operation of strict appointment-based systems. Other facilitators to cervical cancer screening included offer of services for free, personal experience of friends/family who suffered cervical cancer, peer encouragement, spousal/partner support, and having suspicious signs/symptoms. Barriers were more pronounced in earlier phases and largely centred around myths that spread in communities or clinic waiting rooms. Lack of training among health workers impeded implementation. Conclusions: Integrating cervical cancer screening with HIV and sexual/reproductive health services was feasible and acceptable, with less pronounced barriers as programs matured. Addressing individual and program-level barriers can optimise uptake of services.</p
Comparing standard and technology-assisted Peer-delivered CBT for Perinatal Depression: A causal mediation study
Get PDFBackground: The ENHANCE non-inferiority trial that took place in a deprived setting in Pakistan, demonstrated that a technology-assisted digital adaptation of the Thinking Healthy Programme (THPTAP), was no different than the face to face Thinking Healthy Programme in improving symptoms of perinatal depression. Examining potential mechanisms through which THP-TAP improved symptoms of perinatal depression, even in the absence of an intervention effect, is key as it can reveal underlying mechanisms of change, providing insight into features the intervention to target to improve outcomes. The present study examines the mechanisms through which THP-TAP improved symptoms of perinatal depressions (or not) compared to the face to face Thinking Healthy Programme. Methods: We applied a counterfactual-based approach to mediation, interventional effects, to decompose the total effect of THP-TAP intervention on symptoms of perinatal depression into the following pre-specified indirect effects: number of sessions attended; behavioural activation; perceived social support; problem-solving and cognitive-restructuring skills; and peer empathy.Results: Perceived social support in THP-TAP arm mediated an improvement in symptoms of perinatal depression compared to the standard face to face Thinking Healthy Programme group (adjusted mean difference in PHQ-9 scores attributable to perceived social support in the technology-assisted digital adaptation of the Thinking Healthy Programme group compared to WHO-THP group: -0.072, bias corrected 95% CI: -0.170, -0.018). There was no difference to support the indirect effects for all other mediators. Conclusions: Even in the absence of treatment superiority, our findings suggest that levels of perceived social support was an important feature of the THP-TAP intervention, that resulted in improved symptoms of perinatal depression. From a practical perspective, these findings highlight the importance of social connectedness as a mechanism of change, demonstrating that peer-delivered digital psychosocial interventions can successfully cultivate this relational component</p
Environmental hazards from pollution of antibiotics and resistance-driving chemicals in an urban river network from Malawi
Get PDFAfrican communities have a high prevalence of antimicrobial-resistant bacterial carriage, alongside high levels of antibiotic usage and environmental pollution. Limited access to water, sanitation and hygiene infrastructure and wastewater treatment facilities enables the dissemination of resistant bacteria, antimicrobials and antibiotic resistance-driving chemicals (ARDCs) into local rivers. Few data exist quantifying the chemical drivers of antimicrobial resistance (AMR) in urban aquatic environments from African settings. In this longitudinal surveillance study, we investigated an urban river network in Blantyre, Malawi over a continuous 12-month period, identifying a broad-range of chemical pollutants, including antibiotics, common pharmaceuticals, agricultural and industrial chemicals and heavy metals. Antimicrobial concentrations were found at levels selective for AMR and ARDCs exhibited seasonal variations, indicating that deficient sanitation infrastructure and anthropogenic factors result in high antibiotic and ARDC levels entering the river systems, which serve as an important ecological niche for the acquisition, maintenance and transmission of AMR
Persistent pneumococcal colonisation in antiretroviral-treated HIV infection is associated with nasal inflammation
Get PDFDespite systemic viral suppression, people living with HIV (PLHIV) on antiretroviral therapy (ART) remain highly susceptible to pneumococcal colonisation and disease. Here, we show that long-term ART does not restore nasal mucosal immunity. Using flow cytometry, single-cell transcriptomics, and neutrophil functional assays, we identify a persistent mucosal immune signature in PLHIV-ART > 1 yr marked by epithelial-driven neutrophilic inflammation, T cell exhaustion, and cellular senescence. Neutrophils exhibit mitochondrial stress, senescence-associated secretory phenotype (SASP) gene expression, and impaired oxidative burst, particularly in individuals with pneumococcal carriage. Epithelial cells express elevated neutrophil-recruiting ligand genes, while nasal T cells display pro-apoptotic and exhaustion gene profiles. Neutrophilic inflammation is strongly associated with pneumococcal carriage density, implicating a feedforward loop between inflammation and microbial persistence. Our findings reveal tissue-specific immune dysregulation despite ART and suggest that targeting epithelial-immune signalling or neutrophil senescence may offer novel therapeutic avenues to reduce respiratory pathogen burden in PLHIV.</p
Mapping health system resilience in federal Nepal: perspectives and lessons from local government level
Get PDFBackgroundHealth systems worldwide are vulnerable to both acute shocks, which strain the health system for a relatively short period of time, and chronic stressors, which place persistent pressure on the health system. Given Nepal’s frequent exposure to public health threats, recent transition to a federal structure and systemic constraints, strengthening resilience at the local government level has emerged as a critical priority. We assessed the health system resilience capacities and identified gaps at the local government level to inform later interventions.MethodsWe conducted a cross-sectional study using a mixed-methods approach in the local governments of Kapilvastu District. Data collection involved: a review of 21 policy and programme documents, 13 key informant interviews (KIIs), and one stakeholder consultative workshop. Additionally, we conducted secondary data analysis focusing on minimum service standards (MSS), human resource availability, health infrastructure, and the incidence of disasters in the study area. Qualitative data and the workshop reflection reports were analysed using NVivo 11, adopting a thematic framework approach, while quantitative data were descriptively summarized using Microsoft Excel. We shared the key results and validated data with health officials in a local government in Kapilvastu district.ResultsLocal health systems in Nepal encounter both acute shocks, such as frequent episodes of disasters (floods, fires, landslides) and disease outbreaks, and persistent stressors, including an increasing burden of chronic diseases. Although there are some opportunities with quick decision-making and good understanding of the local context among decision makers, the resilience capacity of local health systems is undermined by unclear roles and responsibilities across three tiers of governments, weak coordination, sub-optimal institutional capacity, poor evidence use practices, weak disease surveillance, insufficient financial and human resources and limited financial flexibility. Gaps in medicines and infrastructure were found to reduce public trust and thus the utilization of services. Addressing these issues requires capacitation of local governments to undertake the responsibilities assigned to them, strengthening governance mechanisms, increasing financial flexibility, and improving multi-sectoral coordination.ConclusionAmidst vulnerability to different shocks and stressors, local governments in Nepal encounter substantial capacity gaps. These challenges originate from unclear roles and responsibilities across three tiers of governments, misalignment between responsibility and capacity, insufficient resources and inadequate coordination across the three tiers of government and various sectors
Maximising power with the minimum number of mosquitoes: Designing robust sample sizes for the WHO Cone Bioassay
No full textPower calculations are an essential component of experimental design when evaluating vector control tools. Determining appropriate sample sizes for robustly detecting a difference between treatment groups in a bioassay (or any comparative experiment) is complicated by multiple sources of variation. While modern simulation-based methods exist to account for compounding sources of variation, uptake is slow due to limited availability of training and hardware. Here we present an accessible, user-friendly framework for performing sample size calculations for World Health Organisation (WHO) cone bioassays. Additionally, we conduct a literature review of studies published between 1998 and 2024 to identify sources of variability in WHO cone bioassay methodologies.We use simulation-based methods to assess power in the WHO cone bioassay, utilising the 2013 WHO guidance for phase I laboratory testing of ‘long-lasting’ insecticidal nets as an illustrative example of how sample size impacts detection of differences in mosquito mortality between treatments. Futhermore, we establish plausible variability assumptions across three levels of bioassay variability for the testing of insecticide-treated nets: between nets of the same product, between net pieces from the same net and between replicates on a net piece.We demonstrate that the biggest factor in determining the number of samples, and therefore mosquitoes, needed in an experiment is the effect size to be detected (mortality difference between treatments). Larger mortality differences (e.g. a 20% difference) are readily detected with the phase I guidance yet detecting a 10% difference requires more than triple this sample size. Here, we present a user-friendly browser application to allow researchers to easily design robust WHO cone bioassay experiments (link: Cone Bioassay Sample Size app)
Environmental hazards from pollution of antibiotics and resistance-driving chemicals in an urban river network from Malawi
Get PDFAfrican communities have a high prevalence of antimicrobial-resistant bacterial carriage, alongside high levels of antibiotic usage and environmental pollution. Limited access to water, sanitation and hygiene infrastructure and wastewater treatment facilities enables the dissemination of resistant bacteria, antimicrobials and antibiotic resistance-driving chemicals (ARDCs) into local rivers. Few data exist quantifying the chemical drivers of antimicrobial resistance (AMR) in urban aquatic environments from African settings. In this longitudinal surveillance study, we investigated an urban river network in Blantyre, Malawi over a continuous 12-month period, identifying a broad-range of chemical pollutants, including antibiotics, common pharmaceuticals, agricultural and industrial chemicals and heavy metals. Antimicrobial concentrations were found at levels selective for AMR and ARDCs exhibited seasonal variations, indicating that deficient sanitation infrastructure and anthropogenic factors result in high antibiotic and ARDC levels entering the river systems, which serve as an important ecological niche for the acquisition, maintenance and transmission of AMR
Assessing the prevalence of antimicrobial resistance among pediatric patients at Kamuzu Central Hospital, Malawi
Get PDFIntroduction: Severe bacterial infections cause significant disease burden in developing countries, including Malawi. The situation is compounded by the scarcity of resources, inconsistent availability of antibiotics, and increasing antimicrobial resistance (AMR). Methodology: This was a descriptive retrospective study where we analyzed blood culture results of pediatric patients admitted to Kamuzu Central Hospital (KCH), Lilongwe, Malawi. The data from January 2018 to January 2022 were compared with clinical metadata, and analyzed using the statistical software packages STATA version 16.1 and R version 4.2. Results: The data of 272 isolates from blood culture were obtained; 47.8% (130/272) of participants presented with organisms resistant to first-line antibiotics; 13.4% (22/164) were resistant to second-line antibiotics which included resistance to piperacillin/tazobactam and meropenem. Gram-negative isolates constituted 54.3% (89/164) of the isolates, of which 32% (29/89) were Acinetobacter spp; while 45.7% (75/164) of the isolates were Gram-positive of which 42.7% (32/75) was Staphylococcus aureus. There were 12 Escherichia coli isolates, of which 50% (6/12) were highly resistant to piperacillin/tazobactam. The Fisher’s exact test indicated that the antibiotic prescribed after a blood culture test result was significantly associated with the isolate observed (p = 0.016).Conclusions: This study highlights high rates of AMR to commonly used antibiotics in the pediatric ward at KCH, and calls for the need to revise treatment guidelines in the wake of empiric antibiotic choices for pediatric patients, including intensification of maximal use of blood culture tests as part of management of febrile illnesses and reinforcement of antimicrobial stewardship in pediatric patient care.</p