Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia.

OBJECTIVES: First, to describe the implementation process, benefits and challenges of a multidisciplinary service for pregnant women with cardiac disease in Namibia. Second, to assess pregnancy outcomes in this population. METHODS: In a tertiary hospital in Namibia, a multidisciplinary service was implemented by staff of obstetric and cardiology departments and included preconception counselling, provision of antenatal care and reliable contraception. Management guidelines developed for high-income settings were used, since no locally adapted guidelines were available. A cohort study was performed to assess cardiac, obstetric and fetal outcomes. Included were pregnant women with cardiac disease, referred to this service between 1 August 2016 and 31 July 2018. RESULTS: Important benefits of this service were the integrated approach, improved access to reliable contraception and insight into drivers of poor outcome. Several challenges with use of available guidelines were encountered, as contextual factors specific to lower-income settings were not taken into consideration, such as higher rates of infection or barriers to access care. The cohort consisted of 65 women. Cardiac disease was diagnosed for the first time in 16 (24.6%) women, of whom 11 had pre-existing cardiac disease. These women presented more often with heart failure than women with known heart disease (75.0% vs. 6.1%, RR 12.5, 95% CI 3.9-38.0). Five women died. Cardiac events occurred in twenty-two women of whom eight developed thromboembolic events and two endocarditis. The majority had no indication for prophylaxis, based on available guidelines. Fetal events occurred in 36 pregnancies. After pregnancy more than half of women (35/65, 53.8%) were using long-acting reversible contraception. CONCLUSIONS: Despite several barriers, it was possible to implement a multidisciplinary service in a high-burden setting. Cardiac and fetal event rates in this cohort were high. To improve outcomes the focus should be on availability of context-specific guidelines and better detection of cardiac disease.

The development of Africa's first unified hypertension management guidelines.

Hypertension is a leading cardiovascular risk factor, contributing significantly to morbidity and mortality in Africa. The continent is plagued with a high incidence, coupled with low treatment and control rates. The causes are multifactorial, and among the major causes is an absence of standardized African guidelines for the management of hypertension. Systems of care vary across the continent, with low-income countries having less care than middle-income countries. International guidelines include recommendations for Black populations, but do not account for the cultural and sociodemographic situation of the African. There is therefore the need for African guidelines based on local data to improve the quality of hypertension care. These guidelines will cover the clinical approach to hypertension and its complications at facilities with physicians and nonphysician health workers (NPHW). It will also proffer suggestions for policies to improve the care for patients with hypertension on the continent.

Evaluating the Effectiveness of African School of Hypertension for Non-Physician Health Workers, a Qualitative Study: QuASH Hypertension Study.

Background: The implementation of task sharing and shifting (TSTS) policy as a way of addressing the shortage of physicians and reducing the burden of hypertension in Africa birthed the idea of the African School of Hypertension (ASH). The ASH is saddled with the responsibility of training non-physician health workers across Africa continent in the management of uncomplicated hypertension. Aim: To get feedback from some faculty members and students who participated in the first ASH programme. Methods: This was a cross-sectional exploratory qualitative study conducted among eight students and eight faculty members. Feedback from the program was obtained by conducting in-depth interviews centred on description of course content; expectations and knowledge acquired from ASH; level of interaction between students and faculty members; challenges faced during the ASH; level of implementation of acquired training; and suggestions to improve subsequent ASH programs. Results: The course content of the ASH was described as simple, appropriate and adequate while interaction between students and faculty members were highly cordial and engaging. New knowledge about hypertension management was acquired by the students with different levels of implementation post-graduation. Some identified challenges with the ASH program were poor internet connectivity during lectures, non-uniformity of TSTS policies and hypertension management guidelines across Africa, technical problems with hypertension management app and low participation from other African countries apart from Nigeria. Some recommendations to improve ASH program were development of a uniform hypertension management guideline for Africans, wider publicity of the ASH, interpretation of lectures into French and Portuguese languages and improvement of internet connectivity. Conclusion: The ASH programme has largely achieved its objectives with the very encouraging feedback received from both faculty members and the students. Steps should be taken to address the identified challenges and implement the suggested recommendations in subsequent ASH program to sustain this success.

Access to Essential Medicines and Diagnostic Tests for Cardiovascular Diseases in Maputo City, Mozambique.

Background: To tackle the increasing burden of non-communicable diseases (NCDs) and reduce premature cardiovascular (CV) mortality by a third by the year 2030, countries must achieve 80% availability of affordable essential medicines (EMs) and technologies in all health facilities. Objectives: To evaluate access to EMs and diagnostics for CV diseases in Maputo City, Mozambique. Methods: Using a modified version of World Health Organization (WHO)/Health Action International (HAI) methodology, we collected data on availability and price of 14 WHO Core EMs and 35 CV EMs in all 6 public-sector hospitals, 6 private-sector hospitals, and 30 private-retail pharmacies. Data on 19 tests and 17 devices were collected from hospitals. Medicine prices were compared with international reference prices (IRPs). Medicines were considered unaffordable if the lowest paid worker had to spend more than one day's wage to purchase a monthly supply. Results: Mean availability of CV EMs was lower than that of WHO Core EMs in both public (hospitals: 20.7% vs. 52.6%) and private sectors (retail pharmacies: 21.5% vs. 59.8%; hospitals: 22.2% vs. 50.0%). Mean availability of CV diagnostic tests and devices was lower in public (55.6% and 58.3%, respectively) compared to private sector (89.5% and 91.7%, respectively). Across WHO Core and CV EMs, the median price of lowest priced generic (LPG) and most sold generic (MSG) versions were 4.43 and 3.20 times the IRP, respectively. Relative to the IRP, median price of CV medicines was higher than that of Core EMs (LPG: 4.51 vs. 2.93). The lowest paid worker would spend 14.0 to 17.8 days' wage monthly to undergo secondary prevention. Conclusion: Access to CV EMs is limited in Maputo City owing to low availability and poor affordability. Public-sector hospitals are not well equipped with essential CV diagnostics. This data could inform evidence-based policies for improving access to CV care in Mozambique.

Acute Rheumatic Fever and Rheumatic Heart Disease: Highlighting the Role of Group A Streptococcus in the Global Burden of Cardiovascular Disease.

Group A Streptococcus (GAS) causes superficial and invasive infections and immune mediated post-infectious sequalae (including acute rheumatic fever/rheumatic heart disease). Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are important determinants of global cardiovascular morbidity and mortality. ARF is a multiorgan inflammatory disease that is triggered by GAS infection that activates the innate immune system. In susceptible hosts the response against GAS elicits autoimmune reactions targeting the heart, joints, brain, skin, and subcutaneous tissue. Repeated episodes of ARF-undetected, subclinical, or diagnosed-may progressively lead to RHD, unless prevented by periodic administration of penicillin. The recently modified Duckett Jones criteria with stratification by population risk remains relevant for the diagnosis of ARF and includes subclinical carditis detected by echocardiography as a major criterion. Chronic RHD is defined by valve regurgitation and/or stenosis that presents with complications such as arrhythmias, systemic embolism, infective endocarditis, pulmonary hypertension, heart failure, and death. RHD predominantly affects children, adolescents, and young adults in LMICs. National programs with compulsory notification of ARF/RHD are needed to highlight the role of GAS in the global burden of cardiovascular disease and to allow prioritisation of these diseases aimed at reducing health inequalities and to achieve universal health coverage.