Xpert Ultra Assay on Stool to Diagnose Pulmonary Tuberculosis in Children.

BACKGROUND: The World Health Organization recommends the Xpert MTB/RIF Ultra assay for diagnosing pulmonary tuberculosis (PTB) in children. Though stool is a potential alternative to respiratory specimens among children, the diagnostic performance of Xpert Ultra on stool is unknown. Thus, we assessed the diagnostic performance of Xpert Ultra on stool to diagnose PTB in children. METHODS: We conducted a cross-sectional study among consecutively recruited children (< 15 years of age) with presumptive PTB admitted in 4 tertiary care hospitals in Dhaka, Bangladesh, between January 2018 and April 2019. Single induced sputum and stool specimens were subjected to culture, Xpert, and Xpert Ultra. We considered children as bacteriologically confirmed on induced sputum if any test performed on induced sputum was positive for Mycobacterium tuberculosis and bacteriologically confirmed if M. tuberculosis was detected on either induced sputum or stool. RESULTS: Of 447 children, 29 (6.5%) were bacteriologically confirmed on induced sputum and 72 (16.1%) were bacteriologically confirmed. With "bacteriologically confirmed on induced sputum" as a reference, the sensitivity and specificity of Xpert Ultra on stool were 58.6% and 88.1%, respectively. Xpert on stool had sensitivity and specificity of 37.9% and 100.0%, respectively. Among bacteriologically confirmed children, Xpert Ultra on stool was positive in 60 (83.3%), of whom 48 (80.0%) had "trace call." CONCLUSIONS: In children, Xpert Ultra on stool has better sensitivity but lesser specificity than Xpert. A high proportion of Xpert Ultra assays positive on stool had trace call. Future longitudinal studies on clinical evolution are required to provide insight on the management of children with trace call.

Utilization of insecticide-treated bed nets and care-seeking for fever and its associated socio-demographic and geographical factors among under-five children in different regions: evidence from the Myanmar Demographic and Health Survey, 2015-2016.

BACKGROUND: Malaria is one of the top-five contributors to under-5 deaths in Myanmar. Use of insecticide-treated nets (ITN) and receiving early appropriate care in case of fever are the core interventions to prevent malaria and its complications and thereby deaths. This study aimed to assess among the under-five children, (a) utilization of ITNs and its associated factors, (b) care-seeking behaviour among their caregivers and its associated factors and uptake of malaria testing among those with fever in the last 2 weeks. METHODS: This was a cross sectional study using secondary analysis of Myanmar Demographic and Health Survey (MDHS) conducted in 2015-2016. Multivariable logistic regression was used to explore the factors associated with non-utilization of ITNs and not seeking care for fever. Effect sizes have been presented using odds ratios with 95% confidence intervals. Data analysis was done using svyset command in STATA to account for the multi-stage sampling design of the survey. RESULTS: Of 4597 alive under-five children, 80.5% did not sleep under an ITN last night. The factors significantly associated with non-utilization of ITNs were residing in malaria elimination regions (aOR = 2.0, 1.3-3.2), urban residence (aOR = 1.8, 1.2-2.9), staying in delta region (aOR = 8.7, 4.7-12.2), hilly region (aOR = 3.0, 2.0-4.6, and having highest wealth quintile (aOR = 1.8, 1.1-3.0). Around 16% had fever in the last 2 weeks, of whom 66.7% sought care for fever and 3% got tested for malaria. Nearly half (50.9%) of the caregivers sought care from a government health facility, followed by private hospital/doctor (27.8%), shop (8.0%), village health worker (4.4%) and pharmacy (3.1%). The factors associated with not seeking care for fever were residing in specific geographical locations (hilly, delta and central plains compared to coastal region) and having lowest wealth quintile (aOR = 2.3, 1.1-5.7). CONCLUSIONS: This study highlighted that ownership and utilization of ITNs was very poor among under-5children. Care-seeking behaviour of the caregivers of under-5 children in case of fever was dismal with two-thirds not seeking care. The programme should seriously consider addressing these barriers if Myanmar is to achieve zero malaria deaths by 2030.

Effect of the Xpert MTB/RIF on the detection of pulmonary tuberculosis cases and rifampicin resistance in Shanghai, China.

BACKGROUND: Xpert MTB/RIF (Xpert) is an automated molecular test recommended by World Health Organization (WHO) for diagnosis of tuberculosis (TB). This study evaluated the effect of Xpert implementation on the detection of pulmonary TB (PTB) and rifampicin-resistant TB (RR-TB) cases in Shanghai, China. METHODS: Xpert was routinely implemented in 2018 for all presumptive PTB patients. All PTB patients above 15 years-old identified within the Provincial TB Control Program during the first half of each of 2017 and 2018, were enrolled to compare the difference in proportions of bacteriological confirmation, patients with drug susceptibility test (DST) results for rifampicin (ie, DST coverage) and RR-TB detection before and after Xpert's implementation. RESULTS: A total of 6047 PTB patients were included in the analysis with 1691 tested by Xpert in 2018. Percentages of bacteriological confirmation, DST coverage and RR-TB detection in 2017 and 2018 were 50% vs. 59%, 36% vs. 49% and 2% vs. 3%, respectively (all p-values < 0.05). Among 1103 PTB patients who completed sputum smear, culture and Xpert testing in 2018, Xpert detected an additional 121 (11%) PTB patients who were negative by smear and culture, but missed 248 (23%) smear and/or culture positive patients. Besides, it accounted for an increase of 9% in DST coverage and 1% in RR-TB detection. The median time from first visit to a TB hospital to RR-TB detection was 62 days (interquartile range -IQR 48-84.2) in 2017 vs. 9 days (IQR 2-45.7) in 2018 (p-value < 0.001). In the multivariate model, using Xpert was associated with decreased time to RR-TB detection (adjusted hazard ratio = 4.62, 95% confidence interval: 3.18-6.71). CONCLUSIONS: Integrating Xpert with smear, culture and culture-based DST in a routine setting significantly increased bacteriological confirmation, DST coverage and RR-TB detection with a dramatic reduction in the time to RR-TB diagnosis in Shanghai, China. Our findings can be useful for other regions that attempt to integrate Xpert into routine PTB and RR-TB case-finding cascade. Further study should focus on the identification and elimination of operational level challenges to fully utilize the benefit of rapid diagnosis by Xpert.

Factors associated with influenza-like illness in care homes in Cheshire and Merseyside during the 2017-2018 influenza season.

OBJECTIVES: The aim of the study was to identify care home characteristics associated with reported care home influenza outbreaks and factors associated with increased transmission of influenza-like illness (ILI) in care homes in Cheshire and Merseyside during the 2017-2018 influenza season. STUDY DESIGN: This is a matched case-control study comparing characteristics between care homes with and without a declared influenza outbreak and a retrospective risk factor analysis of care home residents with ILI. METHODS: Routinely collected outbreak surveillance data on symptomatic residents and staff, antiviral prophylaxis and influenza vaccination history, which were reported to Public Health England, were extracted from health protection electronic records. Further care home characteristics were extracted from the Care Quality Commission (CQC) website. Care homes with declared influenza outbreaks were matched with care homes without outbreaks. Chi-squared tests and logistic regression were used to examine associations between care home factors and ILI. RESULTS: There were no significant differences in characteristics between 77 care homes with declared influenza outbreaks and 77 matched care homes without outbreaks. Of 2,744 residents from the homes with a declared outbreak, 644 (24%) developed an ILI. The care home risk factors were having a low CQC score and activation of antiviral prophylaxis and the protective factors were having higher numbers of residents, specializing in dementia care and having the highest CQC score. Significantly more cases occurred in residential homes than in nursing homes, in homes with lower CQC scores and in homes where eligible residents were given antiviral prophylaxis. CONCLUSIONS: In homes with declared outbreaks, certain characteristics including activation of antiviral prophylaxis were associated with an increased risk of ILI. Further research is needed, particularly focussing on temporality between provision of prophylactic antivirals and the onset of ILI.

How complete were maternal death reviews in Central Kenya 2015 - 2018?

In response to high maternal mortality ratio (MMR) Kenya implemented mandatory maternal death reviews (MDR) in 2004. This retrospective study used MDR data to assess the completeness of MDR process in seven hospitals of Thika sub-county, central Kenya from January 2015 to June 2018. Of all 43 maternal deaths that occurred, 98% were notified while 64% were audited. MDR forms were filled in 55% of the cases of which only 7% had complete documentation. The median age of patients was 30 years majority of whom died within 24 hours of admission. Caesarean sections were associated with 48% of deaths, with haemorrhage accounting for most of the direct causes. Data on hospital-related delays, missed opportunities and action points were most frequently omitted in MDR forms. Capacity building for audit teams is recommended to improve quality of MDR process particularly focusing on identifying causes of preventable maternal deaths.

Barriers in distribution, ownership and utilization of insecticide-treated mosquito nets among migrant population in Myanmar, 2016: a mixed methods study.

BACKGROUND: Sleeping under insecticide-treated mosquito nets/long-lasting insecticidal nets (ITNs/LLINs henceforth referred to as ITNs) is one of the core interventions recommended by the World Health Organization to reduce malaria transmission and prevent malaria in high-risk communities, such as migrants, by preventing mosquito bites. The malaria burden among the migrant population is a big challenge for malaria elimination in Myanmar. In this context, this study aimed to assess the ownership and utilization of ITNs and to understand the barriers to distribution and utilization of ITNs among the high-risk migrant communities in the Regional Artemisinin Resistance Initiative (RAI) project areas of Myanmar. METHODS: A sequential mixed methods study (quantitative component: cross-sectional study involving analysis of secondary data available from a survey conducted among migrant households in the RAI project areas of Myanmar in 2016 followed by a descriptive qualitative component in 2018). A total of 17 focus group discussions (involving 121 participants) with different groups of migrants and 17 key-informant interviews with key programme stakeholders were conducted in 4 selected townships of RAI project areas. RESULTS: Of 3230 migrant households, 63.3% had at least one ITN while 36% had sufficient ITNs (i.e., 1 ITN per 2 persons). Regarding ITN utilization, about 52% of household members reported sleeping under an ITN the previous night, which is similar among under-fives and pregnant women. Over half of all bed nets were ITNs, with nearly one-third having holes or already undergone repairs. The qualitative findings revealed that the key challenges for ITN utilization were insufficient ITNs in households and dislike of ITNs. The barriers to ITN distribution were incomplete migrant mapping due to resource constraints (time, money, manpower) and difficulties in transportation and carrying ITNs. CONCLUSION: This study highlights poor ownership and utilization of ITNs among migrants in the RAI project areas of Myanmar and barriers to their ownership and utilization. To achieve universal coverage and utilization, more programmatic support by the programme is needed to carry out complete migrant mapping and continuous ITN distribution in remote locations.

Clinical and equipment-related factors associated with the adequate peripheral blood stem cell collection in autologous transplant at a tertiary cancer center in Kerala - A retrospective cohort study.

BACKGROUND: PBSC collection using apheresis is the preferred source of hematopoietic stem cells transplantation. However, apheresis procedures fail to harvest adequate CD34 yield in 5 to 40% of patients during the first collection. Therefore, this study aimed to study both the clinical- and equipmentrelated factors influencing CD34 yield among the autologous patients and to compare the collection efficiency of two apheresis equipments(Haemonetics MCS+ and Terumo Spectra Optia). METHODS: Retrospective analysis of 69 patients underwent PBSC collection from 2015 to 2018. Frequency, clinical- and equipment-related factors responsible for adequate CD34+ cells (≥2 x106 cells/kg) yield during the first collection was studied. Factors such as collection efficiency, percentage platelet loss and percentage hemoglobin loss were considered to compare the two apheresis system. RESULTS: Two-third (72%) patients of the study population had adequate CD34 stem cells yield during the first collection. Factors such as exposure to lenalidomide-based pretreatment regimen, peripheral blood WBC count and CD34 count are associated with the adequate CD34 yield. Optia had a slightly better collection efficiency than MCS+ (50 and 44; p=0.37). Optia had lower product volume (237 vs 298 ml) and lesser procedure duration (277 vs 360 min), whereas the median Hb loss (3.0% and 2.3%) and mean platelet loss (49% and 34%) were higher with MCS. CONCLUSION: This study infers that the collection efficiency of both the equipments in collecting CD34 stem cells was similar. However, during PBSC collection, procedures using Optia can be preferred to MCS+ on the patients with risk of anemia and thrombocytopenia.

Frequency, characteristics and hospital outcomes of road traffic accidents and their victims in Guinea: a three-year retrospective study from 2015 to 2017.

BACKGROUND: Road traffic accidents (RTA) remain a global public health concern in developing countries. The aim of the study was to document the frequency, characteristics and hospital outcomes of road traffic accidents in Guinea from 2015 to 2017. METHODS: We conducted a retrospective cohort study using medical records of RTA victims from 20 hospitals and a cross-sectional study of RTA cases from eight police stations in eight districts in Guinea, West Africa. Data analysis included descriptive statistics, trends of RTA, a sequence of interrupted time-series models and a segmented ordinary least-squares (OLS) regression. RESULTS: Police stations recorded 3,140 RTA over 3 years with an overall annual increase in RTA rates from 14.0 per 100,000 population in 2015, to 19.2 per 100,000 population in 2016 (37.1% annual increase), to 28.7 per 100,000 population in 2017 (49.5% annual increase). Overall, the injury rates in 2016 and 2017 were .05 per 100,000 population higher on average per month (95% CI: .03-.07). Deaths from RTA showed no statistical differences over the 3 years and no association of RTA trends with season was found. Overall, 27,751 RTA victims were admitted to emergency units, representing 22% of all hospitals admissions. Most victims were males (71%) and young (33%). Deaths represented 1.4% of all RTA victims. 90% of deaths occurred before or within 24 h of hospital admission. Factors associated with death were being male (p = .04), being a child under 15 years (p = .045) or an elderly person aged ≥65 years (p < .001), and having head injury or coma (p < .001). CONCLUSIONS: RTA rates in Guinea are increasing. There is a need for implementing multisectoral RTA prevention measures in Guinea.

Pattern of skin diseases in children attending a dermatology clinic in a referral hospital in Wolaita Sodo, southern Ethiopia.

BACKGROUND: Epidemiological studies to determine the pattern of skin diseases among children are important for proper health care planning and management. The purpose of this study was to describe the pattern of skin diseases among pediatric patients seen at a dermatology outpatient clinic of Wolaita Sodo Teaching and Referral Hospital, southern Ethiopia. METHOD: We conducted a retrospective hospital-based, cross-sectional study between January 2016 and December 2017 at a teaching and referral hospital dermatology outpatient department. All children younger than 15 years presenting with newly-diagnosed skin diseases were included. Diagnosis was mainly made clinically, with some laboratory support. RESULTS: A total of 1704 children with 1869 new skin diagnoses were included, of whom 139 (8.2%) had more than one disease. Of the children, 52.4% were males and 44.9% within the age-group 5-10 years. Eczematous dermatitis accounted for the largest group (23.9%, n = 447) of skin conditions followed by bacterial infections (21.3%, n = 398), fungal infections (18.8%, n = 351) and infestations (9.9%, n = 185). Seasonal variation was demonstrated, with eczematous conditions and bacterial infections being higher during autumn and winter. CONCLUSION: Overall, eczema, bacterial and fungal infections were the three major pediatric skin diseases occurring among children attending this hospital's outpatient department. There was seasonal variation in some of the skin diseases. This study gives a snapshot of skin disorders presenting to hospital in children in southern Ethiopia and may help to plan dermatology service expansion, educational programs and preventive measures.

Are they there yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse - a mixed methods study from Karnataka, India.

BACKGROUND: Tobacco use and alcohol abuse are associated with higher risk of tuberculosis (TB) infection, progression to active TB and adverse treatment outcomes among patients with TB. Revised National Tuberculosis Control Programme (RNTCP) treatment guidelines (2016) require the documentation of tobacco and alcohol use among patients with TB and their linkage to tobacco and alcohol abuse treatment services. This study aimed to assess the extent of documentation of tobacco and alcohol usage data in the TB treatment card and to explore in-depth, the operational issues involved in linkage. METHODS: A convergent parallel mixed methods study was conducted. All new TB treatment cards of adult patients registered under RNTCP between January and June 2017 in Dakshina Kannada district were reviewed to assess documentation. Document review was done to understand the process of linkage (directing patients to tobacco and alcohol abuse treatment services). In-depth interview of health care providers (n = 7) and patients with TB (n = 5) explored into their perspectives on linkage. RESULTS: Among 413 treatment cards reviewed, tobacco use was documented in 322 (78%), of whom 86 (21%) were documented as current tobacco users. Sixteen (19%) out of these 86 patients were linked to tobacco cessation services. Alcohol usage status was documented in 319 (77%) cards of whom 71(17%) were documented as alcohol users. Eleven (16%) out of these 71 patients were linked to alcohol abuse treatment services. The questions in the treatment card lacked clarity. Guidelines on eliciting history of substance abuse and criteria for linkage were not detailed. Perceived enablers for linkage included family support, will power of the patients and fear of complications. Challenges included patient's lack of motivation, financial and time constraints, inadequate guidelines and lack of co-ordination mechanisms between TB programme and tobacco/alcohol abuse treatment services. CONCLUSION: Documentation was good but not universally done. Clear operational guidelines on linkage and treatment guidelines for health care providers to appropriately manage the patients with comorbidities are lacking. Lack of coordination between the TB treatment programme and tobacco cessation as well as alcohol treatment services was considered a major challenge in effective implementation of the linkage services.

Did school characteristics affect the uptake of meningococcal quadrivalent vaccine in Greater Manchester, United Kingdom?

OBJECTIVES: The objective of this study was to assess if school characteristics were associated with the uptake of the meningococcal ACWY (MenACWY) vaccine in Greater Manchester in 2017/18. STUDY DESIGN: This is an ecological cross-sectional study. METHODS: We analysed data on all 129 schools in seven local authorities in Greater Manchester from the Department for Education and from local child health information systems to determine whether school characteristics, including school type and Ofsted effectiveness score, were associated with vaccine uptake. Schools with no eligible pupils were excluded. We undertook single-variable and multivariable analysis and considered key interactions. RESULTS: The overall uptake rate was 80.7%, with a median uptake per school of 80.6% (interquartile range, 69.0%-87.4%). Lower vaccination rates were associated with lower overall effectiveness scores (odds ratio [OR]: 3.54, 95% confidence interval [CI]: 3.00-4.19) and lower numbers of pupils eligible for vaccination (OR: 1.39, 95% CI: 1.28-1.51). Schools with a lower percentage of pupils for whom English is a second language and high deprivation were associated with lower uptake (OR: 1.58, 95% CI: 1.41-1.78). In addition, community schools (the schools with the most local authority oversight) had lower vaccination rates than other categories of schools. CONCLUSIONS: In this study, uptake rates of the MenACWY vaccine were associated with all five school characteristics considered. Effectiveness scores for schools had the largest association with vaccine uptake, with poorer schools having lower uptake. These characteristics should be used by vaccination providers to prioritise their interventions to increase immunisation rates.

Use of prophylactic antivirals and care home characteristics associated with influenza in care homes with confirmed outbreaks.

OBJECTIVES: To assess the association of antiviral prophylaxis and care home characteristics with the spread and severity of influenza-like illness in care homes with influenza outbreaks in North West England in the 2017/2018 influenza season. STUDY DESIGN: This is a retrospective observational study. METHODS: Routinely collected outbreak surveillance data reported to Public Health England were extracted from health protection electronic records. Data included use of antiviral prophylaxis, influenza-like illness or confirmed influenza, hospital admissions and deaths. Care home characteristics were obtained from the Care Quality Commission website. Single variable analysis and multivariable logistic regression were used to examine associations between care home characteristics, antiviral prophylaxis and influenza-related outcomes. RESULTS: In the 109 homes, there were 3498 residents; of whom, 855 (24%) developed an influenza-like illness. Antiviral prophylaxis was given to residents of 67 of the 109 care homes with outbreaks (61%). A significantly higher attack rate was observed among residents of homes given antiviral prophylaxis (27%) than among residents of homes not given antivirals (20%) (P < 0.001). Significantly more deaths occurred in homes for people with learning disabilities and homes that received antiviral prophylaxis (P < 0.001). CONCLUSIONS: In homes given antiviral prophylaxis, there were a higher number of residents with influenza-like illness and deaths. To improve our understanding of the impact of antiviral prophylaxis use in real life, enhanced and timely data collection is needed for identification of temporal associations between exposure and administration of antiviral prophylaxis. Consideration needs also to be given to ensure people with learning disabilities are protected through the seasonal influenza vaccine and timely antiviral prophylaxis when appropriate.

Low uptake of malaria testing within 24 h of fever despite appropriate health-seeking among migrants in Myanmar: a mixed-methods study.

BACKGROUND: There is limited information on uptake of malaria testing among migrants who are a 'high-risk' population for malaria. This was an explanatory mixed-methods study. The quantitative component (a cross sectional analytical study-nation-wide migrant malaria survey in 2016) assessed the knowledge; health-seeking; and testing within 24 h of fever and its associated factors. The qualitative component (descriptive design) explored the perspectives of migrants and health care providers [including village health volunteers (VHV)] into the barriers and suggested solutions to increase testing within 24 h. Quantitative data analysis was weighted for the three-stage sampling design of the survey. Qualitative data analysis involved manual descriptive thematic analysis. RESULTS: A total of 3230 households were included in the survey. The mean knowledge score (maximum score 11) for malaria was 5.2 (0.95 CI 5.1, 5.3). The source of information about malaria was 80% from public health facility staff and 21% from VHV. Among 11 193 household members, 964 (8.6%) had fever in last 3 months. Health-seeking was appropriate for fever in 76% (0.95 CI 73, 79); however, only 7% (0.95 CI 5, 9) first visited a VHV while 19% (0.95 CI 16, 22) had self-medication. Of 964, 220 (23%, 0.95 CI 20, 26) underwent malaria blood testing within 24 h. Stable migrants, high knowledge score and appropriate health-seeking were associated with testing within 24 h. Qualitative findings showed that low testing within 24 h despite appropriate health-seeking was due to lack of awareness among migrants regarding diagnosis services offered by VHV, delayed health-seeking at public health facilities and not all cases of fever being tested by VHV and health staff. Providing appropriate behaviour change communication for migrants related to malaria, provider's acceptance for malaria testing for all fever cases and mobile peer volunteer under supervision were suggested to overcome above barriers. CONCLUSIONS: Providers were not testing all migrant patients with fever for malaria. Low uptake within 24 h was also due to poor utilization of services offered by VHV. The programme should seriously consider addressing these barriers and implementing the recommendations if Myanmar is to eliminate malaria by 2030.

Alarming prevalence and clustering of modifiable noncommunicable disease risk factors among adults in Bhutan: a nationwide cross-sectional community survey.

BACKGROUND: Bhutan is currently facing a double burden of non-communicable (NCDs) and communicable diseases, with rising trends of NCDs. The 2014 STEPS survey identified high prevalence of several NCD risk factors; however, associations with socio-demographic characteristics as well as clustering of risk factors were not assessed. This study aimed to determine the distribution and clustering of modifiable NCD risk factors among adults in Bhutan and their demographic and social determinants. METHODS: This was secondary analysis of data from NCD Risk Factors WHO STEPS Survey 2014 in Bhutan. A weighted analysis was conducted to calculate the prevalence of NCD risk factors, and associations were explored using weighted log-binomial regression models. RESULTS: This study included 2822 Bhutanese aged 18-69 years; 52% were 18-39 years, 62% were female, and 69% were rural resident. Prevalence of high salt intake, unhealthy diet and tobacco use were 99, 67 and 25% respectively. Raised blood pressure was the commonest (36%) modifiable biological risk factor followed by overweight (33%). The median NCD risk factors per person was 3 (Inter Quartile Range: 2-4); 52.5%% had > = 3 risk factors. A statistically significant difference was found between male vs. female in alcohol consumption(aPR 0.71, 95% CI: 0.53-0.97), low physical activity(aPR 2.06, 95% CI: 1.54-2.75), impaired fasting glycaemia(aPR 1.24, 95% CI: 1.01-1.52), and being overweight(aPR 1.46, 95% CI: 1.31-1.63). Low physical activity was more common among those with secondary and above education level vs. those without any formal education(aPR 1.71, 95% CI: 1.24-2.35), and among those residing in urban areas vs. those in rural(aPR 3.43, 95% CI: 2.27-5.18). Older participants and urban residents were more likely to have > = 3 NCD risk factors compared to younger(aPR 1.46, 95% CI: 1.35-1.58) and rural residents(aPR 1.21, 95% CI: 1.10-1.32). CONCLUSION: Lifestyle modifications at the population level are urgently required in Bhutan as several NCD risk factors such as high salt intake, unhealthy diet, overweight, and high blood pressure were alarmingly high and frequently clustered. Moreover there is a need to consider policy and socio-political and economic factors that have undermined global and national progress to address the rise of NCDs and their risk factors in Bhutan as elsewhere.

Offering general pediatric care during the hard times of the 2014 Ebola outbreak: looking back at how many came and how well they fared at a Médecins Sans Frontières referral hospital in rural Sierra Leone.

BACKGROUND: In Bo district, rural Sierra Leone, we assessed the burden of the 2014 Ebola outbreak on under-five consultations at a primary health center and the quality of care for under-15 children at a Médecins Sans Frontières (MSF) referral hospital. METHODS: Retrospective cohort study, comparing a period before (May-October 2013) and during the same period of the Ebola outbreak (2014). Health worker infections occurred at the outbreak peak (October 2014), resulting in hospital closure due to fear of occupational-risk of contracting Ebola. Standardized hospital exit outcomes and case fatality were used to assess quality of care until closure. RESULTS: A total of 13,658 children under-five, were seen at the primary health center during 2013 compared to 8761 in 2014; a consultation decline of 36%. Of 6497 children seen in the hospital emergency room, during the outbreak, patients coming from within hospital catchment area declined with 38% and there were significantly more self-referrals (80% vs. 61%, P < 0.001). During Ebola, 23 children were dead on arrival and the proportion of children in severe clinical status (requiring urgent attention) was higher (74% during Ebola vs. 65% before, P < 0.001). Of 5,223 children with available hospital outcomes, unfavorable outcomes (combination of deaths and abandoned) were less than 15% during both periods, which is within the maximum acceptable in-house threshold set by MSF. Case fatality for severe malaria and lower respiratory tract infections (n = 3752) were similar (≤15%). CONCLUSIONS: Valuable and good quality pediatric care was being provided in the pediatric hospital during the 2014 Ebola outbreak, but could not be sustained because of hospital closure. Health facility and health worker safety should be tackled as a universal requirement to try to avoid a déjà-vu.

Using mobile phones to ensure that referred tuberculosis patients reach their treatment facilities: a call that makes a difference.

BACKGROUND: Over the last decade, the availability and use of mobile phones have grown exponentially globally and in Cambodia. In the Sihanouk Hospital Centre of Hope(SHCH) in Cambodia about half of all tuberculosis patients referred out to peripheral health facilities for TB treatment initiation or continuation were lost to contact after referral ranging from 19 to 69% between 2008 and 2013. To address this, we implemented a mobile phone-based patient tracking intervention. Here, we report the number and proportion of referred TB patients who could be contacted through a mobile phone and retained in care after the introduction of mobile phone tracking. METHODS: A descriptive study involving follow-up of TB patients referred out from SHCH to peripheral health facilities during May-October 2014. Standard operating procedures were used to contact individual patients and/or health facilities using a mobile phone. RESULTS: Among 109 TB patients referred to peripheral health facilities, 107(98%) had access to a mobile phone of whom, 103(97%) could be contacted directly while 5(2%) were contacted through their health care providers. A total of 108(99%) of 109 referred TB patients in intervention period were thus placed on TB treatment. CONCLUSIONS: This study provides preliminary, but promising evidence that using mobile phones was accompanied with improved retention of referred TB patients compared to historical cohorts. Given the limitations associated with historical controls, we need better designed studies with larger sample size to strengthen the evidence before national scale-up.

HIV testing uptake and retention in care of HIV-infected pregnant and breastfeeding women initiated on 'Option B+' in rural Zimbabwe.

OBJECTIVES: Zimbabwe has started to scale up Option B+ for the prevention of mother-to-child transmission of HIV, but there is little published information about uptake or retention in care. This study determined the number and proportion of pregnant and lactating women in rural districts diagnosed with HIV infection and started on Option B+ along with six-month antiretroviral treatment (ART) outcomes. METHODS: This was a retrospective record review of women presenting to antenatal care or maternal and child health services at 34 health facilities in Chikomba and Gutu rural districts, Zimbabwe, between January and March 2014. RESULTS: A total of 2728 women presented to care of whom 2598 were eligible for HIV testing: 76% presented to antenatal care, 20% during labour and delivery and 4% while breastfeeding. Of 2097 (81%) HIV-tested women, 7% were HIV positive. Lower HIV testing uptake was found with increasing parity, late presentation to antenatal care, health centre attendance and in women tested during labour. Ninety-one per cent of the HIV-positive women were started on Option B+. Six-month ART retention in care, including transfers, was 83%. Loss to follow-up was the main cause of attrition. Increasing age and gravida status ≥2 were associated with higher six-month attrition. CONCLUSION: The uptake of HIV testing and Option B+ is high in women attending antenatal and post-natal clinics in rural Zimbabwe, suggesting that the strategy is feasible for national scale-up in the country.

Is adjunctive naturopathy associated with improved glycaemic control and a reduction in need for medications among type 2 Diabetes patients? A prospective cohort study from India.

BACKGROUND: With an estimated 65 million Diabetes Mellitus (DM) patients, India ranks second in the world in terms of DM burden. The emphasis of current medical practice has been on pharmacotherapy but, despite the best combination therapies, acheiving glycaemic control (reduction of blood sugar to desirable levels) is a challenge. 'Integrated Naturopathy and Yoga'(INY) is an alternative system of medicine that lays emphasis on the role of diet and physical exercise. We assessed the short term effect of INY as an adjunct to pharmacotherapy on glycaemic control among type 2 DM patients. METHODS: In this prospective cohort study with a 3 month follow-up, DM patients consecutively admitted to a hospital in India from May-October 2014 for either 15 or 30 days were offered INY - a package of vegetarian diet with no added oil, sugar and salt, yoga-based exercise, patient counselling and rest. A 'favourable outcome' was defined as glycaemic control (glycosylated hemoglobin (HbA1c) < 7 % or absolute reduction by 1 %) along with at least 50 % reduction in antidiabetes medication at 3 months relative to baseline. Compliance to diet was scored by self-report on a scale of 0-10 and categorized into poor (0-5), moderate (6-8) and excellent (9-10). RESULTS: Of 101 patients with 3-month follow-up data, 65(65 %) achieved a favourable outcome - with 19(19 %) stopping medication while sustaining glycemic control. Factors associated with favourable outcome were baseline HbA1c and compliance to diet, which showed a significant linear relationship with mean HbA1c reductions of 0.4 %, 1.1 % and 1.7 % in relation to poor, moderate and excellent dietary compliance respectively. CONCLUSION: INY, adjunctive to pharmacotherapy, was associated with a significant beneficial effect on glycaemic control and reduced the overall need for antidiabetes medications. These early results are promising. Further studies with long-term follow-up and using more rigorous randomized controlled trial designs are needed.

Medication Adherence Clubs: a potential solution to managing large numbers of stable patients with multiple chronic diseases in informal settlements.

OBJECTIVES: To assess the care of hypertension, diabetes mellitus and/or HIV patients enrolled into Medication Adherence Clubs (MACs). METHODS: Retrospective descriptive study was carried out using routinely collected programme data from a primary healthcare clinic at informal settlement in Nairobi, Kenya. All patients enrolled into MACs were selected for the study. MACs are nurse-facilitated mixed groups of 25-35 stable hypertension, diabetes mellitus and/or HIV patients who met quarterly to confirm their clinical stability, have brief health discussions and receive medication. Clinical officer reviewed MACs yearly, when a patient developed complications or no longer met stable criteria. RESULTS: A total of 1432 patients were enrolled into 47 clubs with 109 sessions conducted between August 2013 and August 2014. There were 1020 (71%) HIV and 412 (29%) non-communicable disease patients. Among those with NCD, 352 (85%) had hypertension and 60 (15%) had DM, while 12 had HIV concurrent with hypertension. A total of 2208 consultations were offloaded from regular clinic. During MAC attendance, blood pressure, weight and laboratory testing were completed correctly in 98-99% of consultations. Only 43 (2%) consultations required referral for clinical officer review before their routine yearly appointment. Loss to follow-up from the MACs was 3.5%. CONCLUSIONS: This study demonstrates the feasibility and early efficacy of MACs for mixed chronic disease in a resource-limited setting. It supports burden reduction and flexibility of regular clinical review for stable patients. Further assessment regarding long-term outcomes of this model should be completed to increase confidence for deployment in similar contexts.

Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea.

OBJECTIVES: Female genital fistula remains a public health concern in developing countries. From January 2007 to September 2013, the Fistula Care project, managed by EngenderHealth in partnership with the Ministry of Health and supported by USAID, integrated fistula repair services in the maternity wards of general hospitals in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7 years of work involving 2116 women repaired in three hospitals across the country. METHODS: This was a retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The study data were reviewed during the period April to August 2014. RESULTS: The majority of the 2116 women who underwent surgical repair had vesicovaginal fistula (n = 2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3 months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up. CONCLUSION: Routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.