Hepatitis A and B among newly arrived refugees: Vaccinate all, or test first for immunity?

AIM: When screening newly arrived refugees, physicians must decide whether to vaccinate against hepatitis A and B at first encounter, thereby minimising missed opportunity, or to test for immunity and vaccinate only the susceptible, minimising unnecessary intervention. Better knowledge of hepatitis A and B immunity in refugee populations from different parts of the world is needed. METHOD: Overseas and domestic medical records of refugees from Africa, Asia, and the Middle East who entered Marion County (Indiana) between 1 September 2016 and 31 December 2017 were reviewed. RESULTS: Of 1191 refugees, 1163 and 1153 were tested for immunity to hepatitis A and B respectively. Among <19 year-olds, immunity to hepatitis A ranged from 52.1% to 79.6%, and immunity to hepatitis B ranged from 75.5% to 87.6%. Among ≥19 year-olds, immunity to hepatitis A was greater than 90% for each of the three regions, whereas immunity to hepatitis B ranged from 19.3% to 94.4%. 96% of refugees in the subset of Burmese ≥19 years old were immune to hepatitis B. Of individuals immune to hepatitis B, immunity was due to vaccination in 94.1% of <19 year-olds and 57.4% of ≥19 year-olds. 10% of refugees with at least three documented doses of hepatitis B vaccine were negative for hepatitis B surface antibody. 34.1% of uninfected refugees with no documented doses of hepatitis B vaccination were positive for hepatitis B surface antibody. CONCLUSION: It is reasonable to begin hepatitis A vaccination of <19 year-olds in this refugee population at first encounter but to test first for hepatitis A susceptibility before vaccinating those ≥19 years old. Similarly delaying hepatitis B vaccination might be appropriate only for a subset of Burmese adults.

Obstacles to surgical services in a rural Cameroonian district hospital.

BACKGROUND: There are significant obstacles to the delivery of surgical care in low income countries. Few studies have defined or characterized these constraints. The present study aimed to identify financial and demographic factors limiting the utilization of surgical services in rural Cameroon. METHODS: A review was performed of all surgical records for patients presenting for surgery at the District Hospital of Kolofata in rural Cameroon over the 3-year study period (2004-2007). Disability-adjusted life years (DALYs) were calculated using disease- and patient-specific outcomes while accounting for postoperative morbidity. Univariate and multivariate analysis identified factors associated with failure to return for care. RESULTS: During the study period, 1,213 patients presented for preoperative evaluation, were informed of the cost to be paid preoperatively, and had surgery scheduled. Of these, 544 patients did not return for treatment, representing 2,163 DALYs potentially lost. Multivariate analysis revealed significant factors associated with increased likelihood of not returning for care as required preoperative payment >$US 310 (OR 0.44-0.86) and a recommended procedure for cancer (OR 0.47-0.86) or cutaneous disease (OR 0.28-0.95). Factors associated with increased odds of returning were male gender (OR 1.03-1.98), preoperative payment <$US 50 (OR 2.86-16.2), and a procedure with low DALYs (OR 1.71-9.89). The average cost per DALY for all operations performed was $US 27.13. CONCLUSIONS: Although surgery addresses a significant disease burden and is reported to be a cost-effective public health intervention, utilization is limited by high costs, demographic factors, and patient perceptions of surgical diseases.

Causes and circumstances of death in a district hospital in northern Cameroon, 1993-2009.

INTRODUCTION: In Sub-Saharan Africa (SSA) sound planning is required as interest increases in the decentralization of healthcare financing and the implementation of a sector-wide approach to health care. For this, improved knowledge of national morbidity and mortality is essential. Data from remote areas of SSA are needed to ensure that public health priority-setting and actions reflect the situation in all regions, not just those easily accessed and readily researched. In order to understand the causes, circumstances and changes over time of death in a remote and underserved region, this study sought information on all deaths in a district hospital over a 17 year period. METHODS: The study design was a retrospective review of the hospital records (in registers) of all patients hospitalized in Kolofata District Hospital, a rural public hospital in the Far North Region of Cameroon, 1 January 1993 to 31 December 2009. A line listing was extracted of all 1281 inpatient deaths, and this included dates of admission and death; patient name, address, sex and ethnic group; presenting complaint; duration of symptoms; summary of physical examination; and the diagnosis presumed to be the cause of death. RESULTS: Children under the age of 15 years and males comprised the majority of deaths (63.9% and 56.0%, respectively). Causes of death were related to the seasons. Infectious diseases including acute lower respiratory tract infection, malaria and diarrhoeal diseases were the leading causes of death; AIDS caused most adult deaths. A total of 67% of patients presented within 1 week of symptom onset, and 56.8% of deaths occurred on or before the day after admission. Deaths due to AIDS, malaria and complications of pregnancy increased over time. Among Kolofata District residents, death from vaccine-preventable measles and neonatal tetanus were rare, particularly in the later study years. The proportion of deaths attributed to non-communicable diseases did not increase in the 17 year period. CONCLUSIONS: To reduce mortality in this world region, priority should be given to the prevention and management of lower respiratory tract infections, malaria, diarrhoeal diseases, AIDS, and the complications of pregnancy. The planning of health resources and activities should take into account seasonal variations in the causes of death. Improvements to emergency services and community education that emphasises the need for earlier presentation when ill should reduce deaths that occur soon after hospital admission. Death due to measles and neonatal tetanus has become rare, a reflection of the effectiveness in this area of the national vaccination program.

Advanced abdominal pregnancy: case report and review of 163 cases reported since 1946.

CONTEXT: Though relatively rare, advanced abdominal pregnancy (AAP) can have dramatic and catastrophic consequences for the foetus and the mother. Difficult to diagnose pre-operatively, AAP presents special challenges to the physician working in remote areas with limited resources for diagnosis and management. CASE REPORT: A case of AAP received in our hospital in Kolofata, Cameroon, is presented and followed by a review of 163 other cases reported from 13 countries since 1946. LESSONS LEARNED: A physician working in a remote district with an active maternity service should expect to encounter several cases of AAP during his or her working lifetime. Pre-operative diagnosis of AAP allows time for thoughtful preparation of the patient, family and medical team; however, to be diagnosed, AAP must first be considered. Diagnosis requires a high index of suspicion, and this should be triggered by any of a number of symptoms and signs reported in many cases of AAP. An unusual echographic appearance of the placenta was present in our case and prompted a more thorough investigation that confirmed the diagnosis. This finding has been reported by others and should be added to the list of signs and symptoms that might lead to a diagnosis of AAP in time to save the surgeon from an unpleasant and dangerous surprise.

Knowledge, attitude and practices of snakebite management amongst health workers in Cameroon: Need for continuous training and capacity building.

BACKGROUND: Snakebite has only recently been recognized as a neglected tropical disease by the WHO. Knowledge regarding snakebites and its care is poor both at the population level, and at the health care staff level. The goal of this study was to describe the level of knowledge and clinical practice regarding snakebite among health care staff from Cameroon. METHODS: A two-day training dedicated to snakebite and its care was organized in 2015 in Yaoundé, capital city of Cameroon. A total of 98 health care staff from all over Cameroon attended the training. Prior to and after the training, an evaluation quantified the attendees' level of knowledge. Pre- and post-training evaluations were compared to assess knowledge improvement. RESULTS: Overall, prior to the training knowledge regarding snakebite and care was poor, and wrong beliefs that "pierre noire" or tourniquet were useful in case of snakebite were common. Knowledge was statistically improved after the training. CONCLUSION: Trainings dedicated to all type of health care staff towards snakebite to improve care are needed, this training must take into consideration the context and the targeted population.

Perceptions of malaria transmission, presentation and management in northern Cameroon.

During early 2001, 1197 adult health service users in a poor rural district of northern Cameroon were interviewed in order to discover prevalent beliefs about malaria. The survey included questions about the name of the disease, its cause and transmission, signs and symptoms, cure, and local importance as a cause of sickness and death. Interviewees showed good understanding of the signs and symptoms of malaria, its importance, and its association with the rains. Most felt that either a medical or a herbal treatment could cure malaria. Only 1% identified mosquitoes as a source of transmission. Health education to explore beliefs and to correct misconceptions should precede and accompany the introduction of technological interventions in malaria control programmes in traditional societies.

Snakebite in northern Cameroon: 134 victims of bites by the saw-scaled or carpet viper, Echis ocellatus.

Echis ocellatus is one of the most deadly snakes known to humans, yet the procurement of antivenom for the treatment of these snakebites in Africa has become increasingly difficult and expensive. There is no consensus for the management of victims, and little is known of actual recent experiences with these cases in ordinary health care settings in Africa. All cases of snakebite reliably identified as bites of E. ocellatus and admitted to Kolofata District Hospital, northern Cameroon, from January 1993 to December 2002 were described retrospectively or prospectively. Of 134 cases admitted, 63% were male, three-quarters were aged < 30 years, and 85% survived. Pasteur polyvalent antivenom for Africa was administered intravenously in all but 1 case, but patients rarely received more than 10 mL. In most cases, appropriate antivenom can be administered effectively at a fraction of the recommended dose (20-60 mL), even in patients with serious complications presenting days after having been bitten; however, death is more likely in late presenters.