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Keeping health staff healthy: evaluation of a workplace initiative to reduce morbidity and mortality from HIV/AIDS in Malawi
No full textBACKGROUND: In Malawi, the dramatic shortage of human resources for health is negatively impacted by HIV-related morbidity and mortality among health workers and their relatives. Many staff find it difficult to access HIV care through regular channels due to fear of stigma and discrimination. In 2006, two workplace initiatives were implemented in Thyolo District: a clinic at the district hospital dedicated to all district health staff and their first-degree relatives, providing medical services, including HIV care; and a support group for HIV-positive staff. METHODS: Using routine programme data, we evaluated the following outcomes up to the end of 2009: uptake and outcome of HIV testing and counselling among health staff and their dependents; uptake and outcomes of antiretroviral therapy (ART) among health staff; and membership and activities of the support group. In addition, we included information from staff interviews and a job satisfaction survey to describe health workers' opinions of the initiatives. RESULTS: Almost two-thirds (91 of 144, 63%) of health workers and their dependents undergoing HIV testing and counselling at the staff clinic tested HIV positive. Sixty-four health workers had accessed ART through the staff clinic, approximately the number of health workers estimated to be in need of ART. Of these, 60 had joined the support group. Cumulative ART outcomes were satisfactory, with more than 90% alive on treatment as of June 2009 (the end of the study observation period). The availability, confidentiality and quality of care in the staff clinic were considered adequate by beneficiaries. CONCLUSIONS: Staff clinic and support group services successfully provided care and support to HIV-positive health workers. Similar initiatives should be considered in other settings with a high HIV prevalence
Typifying guinea pig (Cavia porcellus) farmers in urban and peri-urban areas in central and south Côte d'Ivoire
No full textSafety and efficacy of dihydroartemisinin-piperaquine versus artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in Zambian children
No full textBACKGROUND: Malaria in Zambia remains a public health and developmental challenge, affecting mostly children under five and pregnant women. In 2002, the first-line treatment for uncomplicated malaria was changed to artemether-lumefantrine (AL) that has proved to be highly efficacious against multidrug resistant Plasmodium falciparum. OBJECTIVE: The study objective was to determine whether dihydroartemisinin-piperaquine (DHA/PQP) had similar efficacy, safety and tolerability as AL for the treatment of children with uncomplicated P. falciparum malaria in Ndola, Zambia. METHODS: Between 2005 and 2006, 304 children (6-59 months old) with uncomplicated P. falciparum were enrolled, randomized to AL (101) or DHA/PQP (203) and followed up for 42 days. Outcome of treatment was defined according to the standard WHO classification, i.e. early treatment failure (ETF), late clinical failure (LCF, late parasitological failure (LPF) and adequate clinical and parasitological response (ACPR). Recurrent infections were genotyped to distinguish between recrudescence and new infection. RESULTS: No ETF was observed. At day 28, PCR-uncorrected ACPR was 92% in the DHA/PQP and 74% in the AL arm (OR: 4.05; 95%CI: 1.89-8.74; p<0.001). Most failure were new infections and PCR-corrected ACPR was similar in the two study arms (OR: 0.69; 95%CI: 0.22-2.26; p=0.33). Similar results were observed for day 42, i.e. higher PCR-uncorrected ACPR for DHA/PQP, mainly due to the difference observed up to day 28, while the PCR-corrected ACPR was similar: DHA/PQP: 93% (179/192), AL: 93% (84/90), (OR: 0.92; 95%CI: 0.30-2.64; p=0.85). Except for cough, more frequent in the DHA/PQP arm (p=0.04), there were no differences between treatment arms in the occurrence of adverse events. Two serious adverse events were probably associated to AL treatment. CONCLUSION: DHA/PQP was as efficacious, safe and well tolerated in treatment of uncomplicated malaria as AL, though in the latter group more new infections during the follow up were observed. DHA/PQP seems a potential candidate to be used as an alternative first-line or rescue treatment in Zambia. Trial Registration: ISRCTN16263443, at http://www.controlled-trials.com/isrctn
Validation of the FAMACHA((c)) eye colour chart using sensitivity/specificity analysis on two South African sheep farms
No full textA validation study of the FAMACHA((c)) system for clinical evaluation of anaemia due to Haemonchus contortus was conducted on two commercial sheep farms in the summer rainfall region of South Africa. In this region, the Haemonchus season lasts from October to April. On Farm 1 the system was tested over a period of five successive years in consecutive sets of young stud Merino replacement rams and ewes examined at intervals of 3-5 weeks over each Haemonchus season, under routine farming conditions. When FAMACHA((c)) scores of 3, 4, and 5 and haematocrit values of </=22%, </=19%, and </=15% were separately considered to be anaemic, sensitivity on Farm 1 ranged from a maximum of 83% for a haematocrit cut-off of </=15%, to 40% for a haematocrit cut-off of </=22%. Sensitivity increased to 93% when FAMACHA((c)) scores of 2, 3, 4, and 5 were considered anaemic at a cut-off value of </=19%, but the positive predictive value decreased to 0.43, indicating that many non-anaemic animals would be treated. The analysis indicated a high level of classification bias on Farm 1, with the animals consistently being classified one FAMACHA((c)) category lower (i.e. less anaemic) than reality. On Farm 2 the test was conducted over two successive years in yearling rams evaluated at weekly to fortnightly intervals during each worm season. Every ram judged to be in FAMACHA((c)) category 4 or 5 was bled for haematocrit determination, and it was only dewormed with effective anthelmintics if the haematocrit was 15% or lower. When FAMACHA((c)) scores of 3, 4, and 5 and haematocrit values of </=22% and </=19% were separately considered to be anaemic on Farm 2, sensitivity ranged from 64% for a haematocrit cut-off of </=22%, to 80% for a cut-off of </=19%. For identical haematocrit cut-off values and proportions of the sampled flock considered to be diseased as for Farm 1, sensitivity was always higher for Farm 2. On the other hand, further analysis of the data indicated that the magnitude of the error on Farm 1 was very consistent on average over the entire trial period. The results of this study indicate that (i) persons introduced to the system should not only be trained, but also be evaluated for accuracy of application; (ii) the sensitivity of the FAMACHA((c)) diagnostic system should ideally be evaluated at shorter intervals to avoid production losses due to failure to detect anaemic animals which may be at risk of death; (iii) that calibration of the FAMACHA((c)) scoring is essential per individual evaluator, and (iv) that animals should be examined at weekly intervals during periods of the highest worm challenge
Linked response for prevention, care and treatment of HIV/AIDS, STIs and reproductive health issues: results after 18 months of implementation in five operational districts in Cambodia
No full textOBJECTIVES: To describe the implementation and results of the Linked Response (LR) in Cambodia after 18 months of follow-up. METHODS:: The main objectives of the LR are to increase access to STI/HIV prevention, testing, care and treatment and to strengthen existing reproductive health services, through increased linkages within and between public health facilities and community-based services. The LR was piloted in Cambodia in 2008, in two demonstration projects, covering five operational districts (ODs). Routine data were collected and analyzed before (2007), during (2008) and after (2009) the implementation of the LR. RESULTS:: Overall in the five ODs, the proportion of pregnant women, tested for HIV, increased from 6% (1261/21376) in 2007 to 86% (18394/21478) in 2009. Syphilis testing, introduced early 2009, reached similar (85%) coverage as HIV by the end of 2009. Between 2007 and 2009, reproductive indicators also increased: antenatal care coverage (at least one visit) from 80% to 100%, public health facility delivery rates from 26% to 46% and contraceptive prevalence from 24% to 28%. Antiretroviral uptake was high among HIV positive mothers and exposed infants, 84% and 95% respectively, and 3 out of 36 (8%) infants tested so far for HIV were diagnosed positive. However, 6 maternal (HIV-positive women) and 7 child deaths (1 tested positive) occurred during the pregnancy or the 30 week-post-partum follow-up period. CONCLUSIONS:: STI/HIV indicators and follow-up improved after the LR was implemented. Efforts should be pursued to further improve quality of health care services
Clinical practice: the diagnosis of imported malaria in children
No full textThe present paper reviews the diagnosis of imported malaria in children. Malaria is caused by a parasite called Plasmodium and occurs in over 100 countries worldwide. Children account for 10-15% of all patients with imported malaria and are at risk to develop severe and life-threatening complications especially when infected with Plasmodium falciparum. Case-fatality ratios vary between 0.2% and 0.4%. Children visiting friends and relatives in malaria endemic areas and immigrants and refugees account for the vast majority of cases. Symptoms are non-specific and delayed infections (more than 3 months after return from an endemic country) may occur. Microscopic analysis of the thick blood film is the cornerstone of laboratory diagnosis. For pragmatic reasons, EDTA-anticoagulated blood is accepted, provided that slides are prepared within 1 h after collection. Information about the Plasmodium species (in particular P. falciparum versus the non-falciparum species) and the parasite density is essential for patient management. Molecular methods in reference settings are an adjunct for species differentiation. Signals generated by automated hematology analyzers may trigger the diagnosis of malaria in non-suspected cases. Malaria rapid diagnostic tests are reliable in the diagnosis of P. falciparum but not for the detection of the non-falciparum species. They do not provide information about parasite density and should be used as an adjunct (and not a substitute) to microscopy. In case of persistent suspicion and negative microscopy results, repeat testing every 8-12 h for at least three consecutive samplings is recommended. A high index of suspicion and a close interaction with the laboratory may assure timely diagnosis of imported malaria
Population-based biochemistry, immunologic and hematological reference values for adolescents and young adults in a rural population in Western Kenya
No full textBACKGROUND: There is need for locally-derived age-specific clinical laboratory reference ranges of healthy Africans in sub-Saharan Africa. Reference values from North American and European populations are being used for African subjects despite previous studies showing significant differences. Our aim was to establish clinical laboratory reference values for African adolescents and young adults that can be used in clinical trials and for patient management. METHODS AND FINDINGS: A panel of 298, HIV-seronegative individuals aged 13-34 years was randomly selected from participants in two population-based cross-sectional surveys assessing HIV prevalence and other sexually transmitted infections in western Kenya. The adolescent (/=18 years) ratio and the male-to-female ratio was 1ratio1. Median and 95% reference ranges were calculated for immunohematological and biochemistry values. Compared with U.S-derived reference ranges, we detected lower hemoglobin (HB), hematocrit (HCT), red blood cells (RBC), mean corpuscular volume (MCV), neutrophil, glucose, and blood urea nitrogen values but elevated eosinophil and total bilirubin values. Significant gender variation was observed in hematological parameters in addition to T-bilirubin and creatinine indices in all age groups, AST in the younger and neutrophil, platelet and CD4 indices among the older age group. Age variation was also observed, mainly in hematological parameters among males. Applying U.S. NIH Division of AIDS (DAIDS) toxicity grading to our results, 40% of otherwise healthy study participants were classified as having an abnormal laboratory parameter (grade 1-4) which would exclude them from participating in clinical trials. CONCLUSION: Hematological and biochemistry reference values from African population differ from those derived from a North American population, showing the need to develop region-specific reference values. Our data also show variations in hematological indices between adolescent and adult males which should be considered when developing reference ranges. This study provides the first locally-derived clinical laboratory reference ranges for adolescents and young adults in western Kenya
Tackling health workforce shortages during antiretroviral treatment scale-up-experiences from Ethiopia and Malawi
No full textIn many sub-Saharan countries, the health workforce shortage has been a major constraint in the scale-up of antiretroviral treatment. This human resource crisis has led to profound adjustments of the antiretroviral treatment care delivery model in several countries in the region. It also inspired some governments to take swift measures to substantially increase human resources capacity. This article draws on the experience of Malawi and Ethiopia, which have been able to successfully increase their health workforce over a relatively short period, allowing scaling up of antiretroviral treatment. Additional international HIV funding and strong political commitment made possible this exceptional response. Both countries implemented a combination of measures to tackle the human resource crisis: the delegation of medical and administrative tasks to lower health cadres and lay workers, the introduction of new health cadres, the reinforcement of preservice training, and improving health staff remuneration. In particular, the involvement of community and lay health workers in HIV-related service delivery substantially increased the health workforce. The involvement of lay cadres has important long-term implications. To sustain results, continued political commitment, ongoing training and supervision to maintain quality of care, and strategies to avoid attrition among lay cadres will be essential. Although task shifting and involvement of lay cadres allowed bridging of the human resource gap in a short time, other strategies have to be considered simultaneously, and all interventions must be maintained over a longer period to yield results
The HIV/AIDS epidemic in sub-Saharan Africa: thinking ahead on programmatic tasks and related operational research
No full textUntil now, we have all been desperately trying to run behind the HIV/AIDS epidemic and catch up with it, but despite all our efforts, the epidemic remains well ahead of us. In 2010, the antiretroviral treatment (ART) gap was about 60%, AIDS-related deaths were almost two million a year, and on top of these figures, for every one person started on ART, there were two new HIV infections. What is needed to change this situation is to think ahead of the epidemic in terms of the programmatic tasks we will be faced with and try to act boldly in trying to implement those tasks. From a programmatic perspective, we: a) highlight what needs to fundamentally change in our thinking and overall approach to the epidemic; and b) outline a number of key task areas for implementation and related operational research