Delayed entry into HIV care after diagnosis in two specialized care and treatment centres in Cameroon: the influence of CD4 count and WHO staging.

BACKGROUND: Delayed entry into HIV care has complicated the challenges faced in sub-Saharan Africa due to the high HIV burden. A clear knowledge of the factors affecting delayed entry will be essential in directing interventions towards reducing delayed entry into HIV care. There exist very limited data on delayed entry in Cameroon despite its relevance; hence this study was conducted to determine the rate of delayed entry and its associated factors in HIV programmes in Cameroon. METHODS: Data used for this study was routine data obtained from the files of HIV patients who were diagnosed between January 1, 2015 and June 30, 2015 at Limbe and Buea regional hospital HIV centers in the South West region of Cameroon. Data analysis was done using SPSS version 20. RESULTS: Of the 223 patients included in the study, nearly one-quarter of patients (22.4 %) delayed to enter HIV care within 3 months. Those who delayed to enter care were less likely to present at first diagnosis (using HIV rapid test) with symptoms such as fever > 1 month (5 % versus 30 %, p = 0.01) and weight loss > 10 % (13 % versus 48 %, p < 0.001). Alcohol consumption, WHO stage and CD4 count levels were also associated with delayed entry in bivariate analysis. In multivariate analysis only CD4 count greater than 500cells/µl and WHO stages I and II were independently associated with delayed entry into HIV care within 3 months. CONCLUSION: In the South West region of Cameroon, approximately 1 out of 4 patients delay to enter HIV care. This high proportion of patients who delay to enter care correlates to the findings recorded by other studies in sub Saharan Africa. Interventions tackling delayed entry into HIV care might need to be favorably directed towards patients that have high CD4 counts and are at very early WHO clinical stages.

Strengthening laboratory networks in the Central Africa region: A milestone for epidemic preparedness and response.

Background: Health systems in the Central Africa region are among the weakest and least funded in the world. The lack of laboratory networks and adequately trained personnel with clearly defined responsibilities has hampered the implementation of laboratory quality improvement programmes. Global Health Systems Solutions (GHSS) obtained a grant from the Africa Centres for Disease Control and Prevention to develop laboratory networks for disease surveillance and strengthen the quality of laboratory testing in the Central Africa region. Intervention: One year after the grant was awarded on 01 October 2018, GHSS has launched a Regional Integrated Surveillance and Laboratory Network (RISLNET) for Central Africa and developed National Laboratory Strategic Plans and Policies for member states, eight frameworks and guideline documents, as well as a website for RISLNET Central Africa. GHSS has also launched an Extension for Community Health Outcomes platform to supervise laboratories enrolled for accreditation, installed a Basic Laboratory Information System (BLIS) in four laboratories in four member states, and trained 247 laboratory personnel and laboratory experts on BLIS, quality assurance, external quality assurance, Strengthening Laboratory Management Towards Accreditation (SLMTA), quality management systems, and equipment maintenance and calibration. Lessons learnt: Participating laboratories now serve as reference laboratories for COVID-19 testing in various countries. Point-of-care testing, using the GeneXpert platform, has been the central strategy for the scale-up of COVID-19 testing in the Central Africa region. Recommendations: Expanding SLMTA to other laboratories within Central Africa will significantly improve the quality management of laboratories for a better healthcare system.

Implementation of a customised antimicrobial resistance laboratory scorecard in Cameroon, Ethiopia and Kenya.

Background: In low-resource settings, antimicrobial resistance (AMR) is detected by traditional culture-based methods and ensuring the quality of such services is a challenge. The AMR Scorecard provides laboratories with a technical assessment tool for strengthening the quality of bacterial culture, identification, and antimicrobial testing procedures. Objective: To evaluate the performance of the AMR Scorecard in 11 pilot laboratory evaluations in three countries also assessed with the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. Methods: Pilot laboratory evaluations were conducted in Cameroon, Ethiopia and Kenya between February 2019 and March 2019. Assessors with previous SLIPTA and microbiology experience were trained. Assessors performed the laboratory assessments using the SLIPTA and AMR Scorecard tools. Results: Weaknesses in technical procedures and the quality management systems were identified in all areas and all laboratories. Safety had the highest mean performance score (SLIPTA: 68%; AMR Scorecard: 73%) while management review had the lowest (SLIPTA: 32%; AMR Scorecard: 8%) across all laboratories. The AMR Scorecard scores were generally consistent with SLIPTA scores. The AMR Scorecard identified technical weaknesses in AMR testing, and SLIPTA identified weaknesses in the quality management systems in the laboratories. Conclusion: Since the AMR Scorecard identified important gaps in AMR testing not detected by SLIPTA, it is recommended that microbiology laboratories use SLIPTA and the AMR Scorecard in parallel when preparing for accreditation. Expanding the use of the AMR Scorecard is a priority to address the need for quality clinical microbiology laboratory services in support of optimal patient care and AMR surveillance.

Evaluation of corrective actions of feedback from clinicians on Clinical Laboratory Services at Bamenda Regional Hospital Laboratory, Cameroon.

BACKGROUND: Customers' satisfaction is imperative for success. Clinical laboratories continuously strive to attain very high levels of customer satisfaction to serve their clients and maintain accreditation. The concept of customer satisfaction has not yet been asserted in most clinical laboratories in Cameroon. OBJECTIVES: Our objectives were to assess the satisfaction of clinicians with the laboratory services at the Bamenda Regional Hospital Laboratory, identify important challenges, corrective actions implemented and changes in satisfaction. METHODS: This retrospective study reviewed secondary data from clinician satisfaction survey records from March 2017 and November 2017. Challenges and implemented corrective actions were identified for assessed statements of dissatisfaction (dissatisfaction rates ≥ 20%) on the March 2017 survey. Satisfaction rates in March 2017 and November 2017 were compared. RESULTS: High levels of dissatisfaction were observed for general satisfaction, waiting time, communication, duty consciousness, specimen collection and approach on the March 2017 survey. The main challenges identified were: lack of respect for the expected length of the waiting time, poor attitude, inadequate information, staff shortage and inadequate supervision. Statistically significant reductions in rates of dissatisfaction were observed for general satisfaction, waiting time, communication, response to emergencies, issuing of results, specimen collection, approach and duty consciousness. CONCLUSION: Waiting time is a major cause of clinician dissatisfaction with laboratory services. The identification of clinicians' challenges and the effective implementation of corrective actions contribute to improvements in clinician satisfaction.

Haematological reference intervals for healthy adults in Bamenda, Cameroon.

BACKGROUND: In the era of evidence-based medicine, haematological reference intervals are essential for the interpretation of data for clinical decision-making, monitoring of treatment and research. It is not uncommon that reference intervals used in most African countries have been obtained from published scientific literature, textbooks, reagent/instrument manuals. OBJECTIVE: The aim of this study was to determine haematological reference intervals of healthy adults in Bamenda, Cameroon. METHODS: This was a cross-sectional study conducted between June and November 2015. Participants were voluntary blood donors at the Blood Bank Service of the Regional Hospital Bamenda aged between 18 and 65 years. The mean, median and standard deviation of the mean were calculated for each haematological parameter. The 95th percentile reference intervals were determined using the 2.5th and 97.5th percentile. The differences between gender for all the parameters were evaluated using the Kruskal-Wallis test. Significance was determined at the 95% confidence level. RESULTS: Out of a total of 340 participants, 202 (59.4%) were men and 138 (40.6%) were women. The median red blood cell, haemoglobin, haematocrit and mean cell haemoglobin concentration were significantly higher in men than women (p < 0.001). The median white blood cell, absolute lymphocytes count, absolute granulocytes and platelet counts for men were significantly lower than those for women (p < 0.011). CONCLUSION: We propose that the present established haematological reference intervals in this study should be used for clinical management of patients and interpretation of laboratory data for research in Bamenda.

High levels of resistance to nucleoside/nucleotide reverse transcriptase inhibitors in newly diagnosed antiretroviral treatment-naive children in sub-Saharan Africa.

: Exposure of infants to antiretroviral drugs for prevention of mother-to-child transmission can induce resistance to nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs). Data from nine national surveys of pretreatment drug resistance in children newly diagnosed with HIV show high levels of resistance to NRTIs included in first-line antiretroviral treatment (ART) regimens (dual abacavir-lamivudine/emtricitabine resistance). Additional research is needed to determine the impact of NRTI resistance on treatment response and optimize infant ART.

Pattern of Antimicrobial Resistance among Bacterial Isolates from Urogenital Clinical Specimens: A Descriptive Study from the Buea Health District, Cameroon.

INTRODUCTION: Antimicrobial resistance has become a global concern and is particularly affecting developing countries where infectious diseases and poverty are endemic. The effectiveness of currently available antimicrobials is decreasing as a result of increasing resistant strains among clinical isolates. OBJECTIVES: The aim of this study was to determine the resistance pattern of bacterial isolates from different clinical urogenital specimens at different hospitals in the Buea Health District, Cameroon. METHODS: A retrospective study was conducted in three hospital laboratories in the Buea Health District, Cameroon, from June to August 2017. All culture and antimicrobial susceptibility test results of patients who presented at each of the laboratories for urine, vaginal swab or urethral swab cultures from January 2012 to December 2016 were included in the study. Data were analysed using SPSS Windows version 20.0. The comparisons between different isolates' resistance to antimicrobials were performed using the chi-square test. The difference in the resistance of urogenital isolates to various antimicrobials within different years was also compared by the chi-square test. RESULTS: A total of 423 bacterial isolates were obtained from clinical urogenital specimens such as: urine 93 (21.9%), vaginal swab 175 (41.4%) and urethral swab cultures 155 (36.6%). The predominant bacterial isolates were Staphylococcus spp. 320 (75.5%), Escherichia coli 37 (8.7%) and Enterococcus spp. 24 (5.7%). All the isolates showed significantly high resistance rates to amoxicillin/clavulanic acid (67.6% resistant rate, p = 0.025), but most isolates, except those of Staphylococcus, were relatively more susceptible to nitrofurantoin (82.6% susceptibility rate, p = 0.045). However, Staphylococcus spp. was more susceptible to ceftriaxone (91.0% susceptibility rate, p < 0.0001) and cefotaxime (74.4% susceptibility rate, p = 0.034). Generally, most of the isolates showed significantly rising rates of resistance to the majority of the antimicrobials tested from 2012 to 2017. CONCLUSION: Our findings showed a progressively rising rate of antimicrobial resistance in urogenital bacterial isolates over the last 5 years in the Buea Health District. Thus, uncontrolled and irrational use or prescription of these drugs should be avoided to maintain low resistance of highly susceptible antimicrobials.

Viral load testing and the use of test results for clinical decision making for HIV treatment in Cameroon: An insight into the clinic-laboratory interface.

BACKGROUND: The viral load (VL) in patients receiving antiretroviral therapy (ART) is the best predictor of treatment outcome. The anticipated benefits of VL monitoring depend on the actual uptake of VL test results for clinical decisions. The objective of this study was to assess the uptake and utilization of VL test results for clinical decisions on HIV treatment in Cameroon, from 2013 to 2017. METHODS: This was a retrospective cohort analysis of data from files of patients receiving ART at Buea, Limbe, Bamenda and Bafoussam regional hospital HIV treatment centers. A simple random pick of six file blocks was performed in each shelf that corresponded to a year of initiation, and the contents of all selected files were reviewed and the information needed for the study entered a structured questionnaire. The data collected was recorded in Epi Info (version 7.1.5.2), and analyzed using SATA (version 12.1; StataCorp LP). RESULTS: Eight hundred and thirty files were reviewed. The mean duration on ART was 39.4±12 months. Viral load testing uptake was 24.33% and only one VL test had been done by all patients. Approximately 65% of the patients did the first VL after more than 24 months on ART. The median turnaround (TAT) time for VL testing was 6 days (Interquartile range (IQR) 3-7days). Among 201 patients who did a VL test, 94.55% had VL suppression (≤1000copies/mm3). Approximately 54% of the patients with virologic failure were switched to a second-line regimen. CONCLUSIONS: The uptake of viral load testing is low in North West, South West and West Regions of Cameroon. The current TAT for VL testing is plausible. The rate of switch to second line regimen is low. It is time to strengthen the scale up of VL testing and improve the rate of switch to second-line regimen in Cameroon.

Prevention of mother-to-child transmission of the Human Immunodeficiency Virus: investigating the uptake and utilization of maternal and child health services in Tiko health district, Cameroon.

INTRODUCTION: Despite evidence that interventions to prevent mother-to-child transmission (PMTCT) of HIV are effective in ensuring a healthy child and keeping mothers alive, there are many challenges to achieving successful interventions in Cameroon. The study was conducted to investigate factors that affect access to and utilization of maternal and child health (MCH) and PMTCT services among women in Tiko health district in Cameroon. METHODS: We conducted a cross-sectional, descriptive study on women of reproductive age who had experienced a pregnancy using a self-administered, structured questionnaire, in health facilities offering PMTCT services and in communities within the district. RESULTS: Four hundred and thirteen women were interviewed. The majority, 98.4%, of them attended antenatal care (ANC) during their most recent pregnancy. Of these women, 87.4% of them made at least four ANC visits. HIV testing during the first visit among the ANC attendees was 85.5%. Approximately, 92.1% of women who tested for HIV received their results on the same day. All participants reported to have given birth in a health facility during their most recent pregnancy. No education (Odds Ratio [OR] 0.11; 95% CI 0.01-0.83) and acquisition of primary education (OR 0.25; 95% CI 0.06-0.88) was associated with better male partner involvement in PMTCT. CONCLUSION: The uptake of MCH/PMTCT services was high in this study. Further exploration of these levels is warranted so that this model of care and engagement can be replicated in other parts of the country where uptake is low.

Driving hospital transformation with SLMTA in a regional hospital in Cameroon.

BACKGROUND: Inspired by the transformation of the Regional Hospital Buea laboratory through implementation of the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme, hospital management adapted the SLMTA toolkit to drive hospital-wide quality improvement. OBJECTIVE: This paper describes changes in the hospital following the quality improvement activities in hygiene and sanitation, the outpatient waiting area and the surgical and maternity wards. METHODS: In March 2011, hospital management established a quality improvement task force and created a hospital-wide quality improvement roadmap, following the SLMTA model. The roadmap comprised improvement projects, accountability plans, patient feedback forms and log books to track quality indicators including patient wait time, satisfaction level, infection rates, birth outcomes and hospital revenue. RESULTS: There was steady improvement in service delivery during the 11 months after the introduction of the quality improvement initiatives: patient wait time at the reception was reduced from three hours to less than 30 minutes and patient satisfaction increased from 15% to 60%. Treatment protocols were developed and documented for various units, infrastructure and workflow processes were improved and there was increased staff awareness of the importance of providing quality services. Maternal infection rates dropped from 3% to 0.5% and stillbirths from 5% to < 1%. The number of patients increased as a result of improved services, leading to a 25% increase in hospital revenue. CONCLUSION: The SLMTA programme was adapted successfully to meet the needs of the entire hospital. Such a programme has the potential to impact positively on hospital quality systems; consideration should be made for development of a formal SLMTA-like programme for hospital quality improvement.

Decentralised facility-based training as an alternative model for SLMTA implementation: The Cameroon experience.

BACKGROUND: The Strengthening Laboratory Management Toward Accreditation (SLMTA) programme is designed to build institutional capacity to help strengthen the tiered laboratory system. Most countries implement the SLMTA three-workshop series using a centralised model, whereby participants from several laboratories travel to one location to be trained together. OBJECTIVES: We assessed the effectiveness and cost of conducting SLMTA training in a decentralised manner as compared to centralised training. METHODS: SLMTA was implemented in five pilot laboratories in Cameroon between October 2010 and October 2012 by means of a series of workshops, laboratory improvement projects and on-site mentorship. The first workshop was conducted in the traditional centralised approach. The second and third workshops were decentralised, delivered on-site at each of the five enrolled laboratories. Progress was monitored by repeated audits using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. RESULTS: Audit scores for all laboratories improved steadily through the course of the programme. Median improvement was 11 percentage points after the first (centralised) training and an additional 24 percentage points after the second (decentralised) training. The estimated per-laboratory cost of the two training models was approximately the same at US$21 000. However, in the decentralised model approximately five times as many staff members were trained, although it also required five times the amount of trainer time. CONCLUSION: Decentralised SLMTA training was effective in improving laboratory quality and should be considered as an alternative to centralised training.

Building local human resources to implement SLMTA with limited donor funding: The Ghana experience.

BACKGROUND: In 2009, Ghana adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme in order to improve laboratory quality. The programme was implemented successfully with limited donor funding and local human resources. OBJECTIVES: To demonstrate how Ghana, which received very limited PEPFAR funding, was able to achieve marked quality improvement using local human resources. METHOD: Local partners led the SLMTA implementation and local mentors were embedded in each laboratory. An in-country training-of-trainers workshop was conducted in order to increase the pool of local SLMTA implementers. Three laboratory cohorts were enrolled in SLMTA in 2011, 2012 and 2013. Participants from each cohort attended in a series of three workshops interspersed with improvement projects and mentorship. Supplemental training on internal audit was provided. Baseline, exit and follow-up audits were conducted using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. In November 2013, four laboratories underwent official SLIPTA audits by the African Society for Laboratory Medicine (ASLM). RESULTS: The local SLMTA team successfully implemented three cohorts of SLMTA in 15 laboratories. Seven out of the nine laboratories that underwent follow-up audits have reached at least one star. Three out of the four laboratories that underwent official ASLM audits were awarded four stars. Patient satisfaction increased from 25% to 70% and sample rejection rates decreased from 32% to 10%. On average, $40 000 was spent per laboratory to cover mentors' salaries, SLMTA training and improvement project support. CONCLUSION: Building in-country capacity through local partners is a sustainable model for improving service quality in resource-constrained countries such as Ghana. Such models promote country ownership, capacity building and the use of local human resources for the expansion of SLMTA.

The World Health Organization African region laboratory accreditation process: improving the quality of laboratory systems in the African region.

Few developing countries have established laboratory quality standards that are affordable and easy to implement and monitor. To address this challenge, the World Health Organization Regional Office for Africa (WHO AFRO) established a stepwise approach, using a 0- to 5-star scale, to the recognition of evolving fulfillment of the ISO 15189 standard rather than pass-fail grading. Laboratories that fail to achieve an assessment score of at least 55% will not be awarded a star ranking. Laboratories that achieve 95% or more will receive a 5-star rating. This stepwise approach acknowledges to laboratories where they stand, supports them with a series of evaluations to use to demonstrate improvement, and recognizes and rewards their progress. WHO AFRO's accreditation process is not intended to replace established ISO 15189 accreditation schemes, but rather to provide an interim pathway to the realization of international laboratory standards. Laboratories that demonstrate outstanding performance in the WHO-AFRO process will be strongly encouraged to enroll in an established ISO 15189 accreditation scheme. We believe that the WHO-AFRO approach for laboratory accreditation is affordable, sustainable, effective, and scalable.