RESUMEN
Antimicrobials are the most frequently prescribed drug in pediatrics, with an estimated 37% of infants and 61% of hospitalized children having received them. Approximately 20-50% of prescriptions have been shown to be potentially unnecessary or inappropriate. The World Health Organization (WHO) estimates that the continued increase in antimicrobial resistance by the year 2050 will lead to the death of 10 million people per year. This paper describes a protocol to be used in a future study to evaluate the implementation of a quarterly syndromic antibiogram, aimed to improve the use of antibiotics for the treatment of pediatric bacterial infections at the Maputo Central Hospital, Mozambique. This study uses implementation science methods framed by the Dynamic Adaption Process (DAP) and RE-AIM conceptual frameworks to develop a multi-phase, mixed-methods evaluation utilizing qualitative and quantitative approaches. The pediatric inpatient services at HCM consist of approximately 18 physicians and 60 nurses. Additionally, the microbiology laboratory consists of eight laboratory technicians. We anticipate analyzing approximately 9,000 medical records. Qualitative methods include in-depth interviews with clinicians, laboratory technicians, and administrators to explore current knowledge and practices around antibiotic decision making, facilitators and barriers to intervention implementation, as well as acceptability and satisfaction with the intervention roll-out. Qualitative analysis will be performed with NVivo 12 software. Quantitative methods include extracting data from existing records from the pediatric ward of Hospital Central de Maputo (HCM) guided by the RE-AIM framework to explore intervention utilization and other factors influencing its implementation. Quantitative descriptive and inferential statistical analysis will be performed using R Studio statistical software. The findings from this evaluation will be shared with hospital administrators and relevant national policymakers and may be used by the Ministry of Health in deciding to expand this approach to other hospitals. The expected results of this research include the development of standard operating guidelines for the creation, distribution, and use of a quarterly syndromic antibiogram for antibiotic decision making that is informed by local epidemiology. Findings from this study will be used to develop a larger multi-site trial in Mozambique.
Asunto(s)
Antibacterianos , Ciencia de la Implementación , Humanos , Mozambique/epidemiología , Antibacterianos/uso terapéutico , Niño , Niño Hospitalizado , Pruebas de Sensibilidad Microbiana , Lactante , Infecciones Bacterianas/tratamiento farmacológico , Infecciones Bacterianas/microbiología , Preescolar , Prescripciones de Medicamentos/estadística & datos numéricosRESUMEN
BACKGROUND: Antibiotics are globally overprescribed for the treatment of upper respiratory tract infections (URTI), especially in persons living with HIV. However, most URTIs are caused by viruses, and antibiotics are not indicated. De-implementation is perceived as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excessive or inappropriate antibiotic use for URTI, through the employment of evidence-based interventions to reduce these practices. Research into strategies that lead to successful de-implementation of unnecessary antibiotic prescriptions within the primary health care setting is limited in Mozambique. In this study, we propose a protocol designed to evaluate the use of a clinical decision support algorithm (CDSA) for promoting the de-implementation of unnecessary antibiotic prescriptions for URTI among ambulatory HIV-infected adult patients in primary healthcare settings. METHODS: This study is a multicenter, two-arm, cluster randomized controlled trial, involving six primary health care facilities in Maputo and Matola municipalities in Mozambique, guided by an innovative implementation science framework, the Dynamic Adaption Process. In total, 380 HIV-infected patients with URTI symptoms will be enrolled, with 190 patients assigned to both the intervention and control arms. For intervention sites, the CDSAs will be posted on either the exam room wall or on the clinician´s exam room desk for ease of reference during clinical visits. Our sample size is powered to detect a reduction in antibiotic use by 15%. We will evaluate the effectiveness and implementation outcomes and examine the effect of multi-level (sites and patients) factors in promoting the de-implementation of unnecessary antibiotic prescriptions. The effectiveness and implementation of our antibiotic de-implementation strategy are the primary outcomes, whereas the clinical endpoints are the secondary outcomes. DISCUSSION: This research will provide evidence on the effectiveness of the use of the CDSA in promoting the de-implementation of unnecessary antibiotic prescribing in treating acute URTI, among ambulatory HIV-infected patients. Findings will bring evidence for the need to scale up strategies for the de-implementation of unnecessary antibiotic prescription practices in additional healthcare sites within the country. TRIAL REGISTRATION: ISRCTN, ISRCTN88272350. Registered 16 May 2024, https://www.isrctn.com/ISRCTN88272350.
Asunto(s)
Antibacterianos , Infecciones por VIH , Ciencia de la Implementación , Prescripción Inadecuada , Atención Primaria de Salud , Infecciones del Sistema Respiratorio , Adulto , Femenino , Humanos , Masculino , Atención Ambulatoria/organización & administración , Atención Ambulatoria/métodos , Antibacterianos/uso terapéutico , Antibacterianos/administración & dosificación , Sistemas de Apoyo a Decisiones Clínicas , Infecciones por VIH/tratamiento farmacológico , Prescripción Inadecuada/prevención & control , Prescripción Inadecuada/estadística & datos numéricos , Mozambique , Pautas de la Práctica en Medicina/estadística & datos numéricos , Atención Primaria de Salud/organización & administración , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Multicéntricos como AsuntoRESUMEN
Introduction: the number of wild poliomyelitis cases, worldwide, dropped from 350,000 cases in 1988 to 33 in 2018. Acute flaccid paralysis (AFP) surveillance is a key strategy toward achieving global polio eradication. The 2014 Ebola virus disease (EVD) epidemic in West Africa infected over 28,000 people and had devastating effects on health systems in Guinea, Liberia, and Sierra Leone. We sought to assess the effects of the 2014 Ebola outbreak on AFP surveillance in Guinea and Liberia. Methods: a retrospective cross-sectional analysis was performed for Guinea and Liberia to evaluate EVD´s impact on World Health Organization (WHO) AFP surveillance performance indicators during 2012-2015. Results: both Guinea and Liberia met the WHO target non-polio AFP incidence rate nationally, and generally sub-nationally, prior to the EVD outbreak; rates decreased substantially during the outbreak in seven of eight regions in Guinea and 11 of 15 counties in Liberia. Throughout the study period, both Guinea and Liberia attained appropriate overall targets nationally for "notification" and "stool adequacy" indicators, but each country experienced periods of poor regional/county-specific indicator performance. Conclusion: these findings mirrored the negative effect of the Ebola outbreak on polio elimination activities in both countries and highlights the need to reinforce this surveillance system during times of crisis.
Asunto(s)
Fiebre Hemorrágica Ebola , Poliomielitis , Humanos , Fiebre Hemorrágica Ebola/epidemiología , Liberia/epidemiología , Guinea/epidemiología , Estudios Retrospectivos , Estudios Transversales , alfa-Fetoproteínas , Vigilancia de la Población , Poliomielitis/epidemiología , Poliomielitis/prevención & control , Brotes de Enfermedades , Parálisis/epidemiología , Parálisis/etiologíaRESUMEN
Globally, viral pathogens are the leading cause of acute respiratory infection in children under-five years. We aim to describe the epidemiology of viral respiratory pathogens in hospitalized children under-two years of age in Eastern Province of Sierra Leone, during the second year of the SARS-CoV-2 pandemic. We conducted a prospective study of children hospitalized with respiratory symptoms between October 2020 and October 2021. We collected demographic and clinical characteristics and calculated each participant´s respiratory symptom severity. Nose and throat swabs were collected at enrollment. Total nucleic acid was purified and tested for multiple respiratory viruses. Statistical analysis was performed using R version 4.2.0 software. 502 children less than two-years of age were enrolled. 376 (74.9%) had at least one respiratory virus detected. The most common viruses isolated were HRV/EV (28.2%), RSV (19.5%) and PIV (13.1%). Influenza and SARS-CoV-2 were identified in only 9.2% and 3.9% of children, respectively. Viral co-detection was common. Human metapneumovirus and RSV had more than two-fold higher odds of requiring O2 therapy while hospitalized. Viral pathogen prevalence was high (74.9%) in our study population. Despite this, 100% of children received antibiotics, underscoring a need to expand laboratory diagnostic capacity and to revisit clinical guidelines implementation in these children. Continuous surveillance and serologic studies among more diverse age groups, with greater geographic breadth, are needed in Sierra Leone to better characterize the long-term impact of COVID-19 on respiratory virus prevalence and to better characterize the seasonality of respiratory viruses in Sierra Leone.
Asunto(s)
COVID-19 , Virus Sincitial Respiratorio Humano , Infecciones del Sistema Respiratorio , Virus , Niño , Humanos , Lactante , Pandemias , Niño Hospitalizado , Estudios Prospectivos , Sierra Leona/epidemiología , COVID-19/epidemiología , SARS-CoV-2 , Infecciones del Sistema Respiratorio/epidemiologíaRESUMEN
Contraception use and family planning have been shown to save lives and benefit women, their families, and their communities. We conducted a cross-sectional study analyzing data from a 2021 survey that was conducted across eight different regions in Migori County, Kenya to examine the potential role that different factors play in meeting family planning targets. Comparisons are made to data collected in 2018/2019 in order to estimate the change over time of contraception uptake. Descriptive statistics were calculated, the Cochran-Mantel-Haenszel test was used to compare contraception use over time, and multivariable logistic regression was used to model determinants of contraceptive use. Sixty-four percent of respondents in 2021 reported that they currently use some form of contraception, and implants are the most popular contraceptive method. Factors associated with higher contraception usage were region, ages 25-34 years, and marital status. Contraception uptake increased significantly in East Kamagambo following a community-driven sexual and reproductive health intervention by the Lwala Community Alliance, suggesting that increased investment in family planning may be influential. We recommend targeted outreach to population groups with low uptake of contraception and investment in both demand- and supply-side interventions to increase contraceptive uptake. Additional research, especially for populations under 18, is needed to further inform effective investment and policy.
Asunto(s)
Anticoncepción , Anticonceptivos , Femenino , Humanos , Estudios Transversales , Kenia , PrevalenciaRESUMEN
BACKGROUND: Lower respiratory tract infections are the leading cause of mortality in young children globally. In many resource-limited settings clinicians rely on guidelines such as IMCI or ETAT + that promote empiric antibiotic utilization for management of acute respiratory illness (ARI). Numerous evaluations of both guidelines have shown an overall positive response however, several challenges have also been reported, including the potential for over-prescribing of unnecessary antibiotics. The aims of this study were to describe the antibiotic prescribing practices for children less than 24 months of age with symptoms of ARI, that were admitted to Kenema Government Hospital (KGH) in the Eastern Province of Sierra Leone, and to identify the number of children empirically prescribed antibiotics who were admitted to hospital with ARI, as well as their clinical signs, symptoms, and outcomes. METHODS: We conducted a prospective study of children < 24 months of age admitted to the KGH pediatric ward with respiratory symptoms between October 1, 2020 and May 31, 2022. Study nurses collected data on demographic information, medical and medication history, and information on clinical course while hospitalized. RESULTS: A total of 777 children were enrolled. Prior to arrival at the hospital, 224 children (28.8%) reported taking an antibiotic for this illness without improvement. Only 15 (1.9%) children received a chest radiograph to aid in diagnosis and 100% of patients were placed on antibiotics during their hospital stay. CONCLUSIONS: Despite the lives saved, reliance on clinical decision-support tools such as IMCI and ETAT + for pediatric ARI, is resulting in the likely over-prescribing of antibiotics. Greater uptake of implementation research is needed to develop strategies and tools designed to optimize antibiotic use for ARI in LMIC settings. Additionally, much greater priority needs to be given to ensuring clinicians have the basic tools for clinical diagnosis, as well as greater investments in essential laboratory and radiographic diagnostics that help LMIC clinicians move beyond the sole reliance on algorithm based clinical decision making.
Asunto(s)
Algoritmos , Antibacterianos , Humanos , Niño , Preescolar , Sierra Leona , Estudios Prospectivos , Antibacterianos/uso terapéutico , Hospitales Públicos , Toma de DecisionesRESUMEN
Background: An estimated 2.4 million babies died within the first 28 days of life in 2020. The third leading cause of neonatal death continues to be neonatal sepsis. Sepsis-causing bacterial pathogens vary temporally and geographically and, with a rise in multidrug-resistant organisms (MDROs), pose a threat to the neonatal population. Methods: This was a single-center, retrospective study of very low birth weight (VLBW) infants with late-onset sepsis (LOS) admitted to a neonatal unit in South Africa. We aimed to calculate the prevalence of multidrug-resistant (MDR) infections in this population. The data collected included demographic and clinical characteristics, length of hospital stay, risk factors for MDRO and mortality, and microbiology results. Logistic regression was used to assess the association between prespecified risk factors with MDR infections and mortality. Results: Of 2570 VLBW infants admitted, 34% had LOS, of which 33% was caused by MDROs. Infection with Acinetobacter spp., Pseudomonas spp., extended-spectrum beta-lactamase Klebsiella spp., or Escherichia coli was associated with the highest mortality in the LOS cohort. Infants with congenital infections (adjusted odds ratio [aOR], 5.13; 95% CI, 1.19-22.02; P = .028) or a history of necrotizing enterocolitis (aOR, 2.17; 95% CI, 1.05-4.49; P = .037) were at significantly higher risk for MDR infections. Conclusions: More than one-third of LOS cases in VLBW infants were caused by MDROs in this study. MDR infections cause substantial neonatal mortality. Antimicrobial stewardship programs, infection control protocols, and ongoing surveillance are needed to prevent further emergence and spread of MDR infections worldwide.
RESUMEN
Objective: As there are no country-representative data on bacterial sensitivities to guide antimicrobial stewardship (AMS) interventions, an AMS programme was established in the outpatient clinics of three tertiary hospitals in Freetown, Sierra Leone. Methods: The study employed a cross-sectional design to collect antibiotic prescribing data from 370 pregnant women and lactating mothers, 314 children and 229 regular patients in the outpatient clinics of the Princess Christian Maternity Hospital (PCMH), Ola During Children's Hospital and Connaught Hospital (CH), respectively, in April 2022. All data were analysed using Stata Version 16. Results: Of 913 patients, most were female (n=635, 69.5%), treated at PCMH (n=370, 40.5%) and had a bacterial infection (n=661, 72.4%). The indication for prescribing antibiotics was inappropriate in 252 (27.6%) patients. Of the 1236 prescriptions, 393 (31.8%) were made at CH. The duration of antibiotic use was not stated in 230 (18.6%) prescriptions. Overall antibiotic consumption was 55.3 defined daily doses per 1000 outpatient-days. Conclusion: Gaps in antibiotic prescriptions were identified in the outpatient clinics of three national referral hospitals in Sierra Leone. In order to combat antimicrobial resistance, AMS interventions are needed to reduce the prescription of antibiotics for inappropriate indications or without specified duration.
RESUMEN
BACKGROUND: Capacity strengthening initiatives aimed at increasing research knowledge and skills of investigators in low- and middle-income countries (LMICs) have been implemented over the last several decades. With increased capacity, local investigators will have greater leadership in defining research priorities and impact policy change to help improve health outcomes. Evaluations of models of capacity strengthening programs are often limited to short-term impact. Noting the limitations of traditional output-based evaluations, we utilized a broader framework to evaluate the long-term impact of the Vanderbilt Institute in Research Development and Ethics (VIRDE), a decade-old intensive grant development practicum specifically tailored for investigators from LMICs. METHODS: To assess the impact of VIRDE on the research careers of alumni over the past 10 years, we surveyed alumni on research engagement, grant productivity, career trajectory, and knowledge gained in grant writing. Descriptive statistics, including means and total counts, and paired sample t-tests were used to analyze the data. RESULTS: Forty-six of 58 alumni completed the survey. All respondents returned to their home countries and are currently engaged in research. Post-VIRDE grant writing knowledge ratings were significantly greater than pre-VIRDE. The number of respondents submitting grants post-VIRDE was 2.6 times higher than before the program. Eighty-three percent of respondents submitted a total of 147 grants post-VIRDE, of which 45.6% were awarded. Respondents acknowledged VIRDE's positive impact on career growth and leadership, with 88% advancing in career stage. CONCLUSIONS: Gains in grant writing knowledge and grant productivity suggest that VIRDE scholars built skills and confidence in grant writing during the program. A substantial proportion of respondents have advanced in their careers and continue to work in academia in their country of origin. Results show a sustained impact on the research careers of VIRDE alumni. The broader framework for research capacity strengthening resulted in an expansive assessment of the VIRDE program and alumni, illuminating successful program elements and implications that can inform similar capacity strengthening programs.
Asunto(s)
Investigación Biomédica , Países en Desarrollo , Academias e Institutos , Ética en Investigación , Humanos , InvestigadoresRESUMEN
Interpersonal violence (IPV) within intimate partner relationships and gender-based violence remain major public health problems worldwide; 44.8% of Kenyan women have reported experiencing IPV beginning after the age of 15 years (National Bureau of Statistics Nairobi, Kenya, 2015). Combatting IPV and its sequelae is integral to promoting gender equality, a key target of the Sustainable Development Goals. We quantify the lifetime prevalence of IPV among women in two rural Kenyan communities, as well as factors associated with IPV in this area, such as educational attainment and severe depression. We conducted a cross-sectional population-based survey of households in the North and East Kamagambo wards of Migori County, Kenya in May 2018. A questionnaire regarding IPV was given to female respondents. Group-wise comparisons and multiple logistic regression analyses were performed to describe community prevalence and factors associated with IPV against women. A total of 873 women completed questions about IPV, representing a population estimate of 11,252 women in the study area. Lifetime IPV prevalence in the study area was 60.3%. Variables associated with IPV included involvement in a polygamous marriage (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: [1.13, 2.88]; p = .013), attaining six or fewer years of education (aOR: 1.84; 95% CI: [1.27, 2.66]; p = .001), and IPV exposure in girlhood (aOR: 1.59; 95% CI: [1.12, 2.28]; p = .011). IPV was independently associated with experience of emotional abuse (OR: 11.22; 95% CI: [7.02, 17.95]; p < .001) and severe depression (OR: 3.51; 95% CI: [1.03, 11.97]; p = .045). Violence against women is a public health emergency in Migori County, Kenya. Low educational attainment, IPV exposure in girlhood, and polygamy were significantly associated with experience of IPV. Our results provide hyper-local data necessary for targeted interventions and generalizable data with sampling methods for use by other implementing organizations in sub-Saharan Africa.
Asunto(s)
Violencia de Pareja , Adolescente , Estudios Transversales , Femenino , Humanos , Kenia/epidemiología , Masculino , Prevalencia , Factores de Riesgo , Parejas Sexuales/psicología , ViolenciaRESUMEN
INTRODUCTION: Narrow, unidimensional measures of poverty often fail to measure true poverty and inadequately capture its drivers. Multidimensional indices of poverty more accurately capture the diversity of poverty. There is little research regarding the association between multidimensional poverty and depression. METHODS: A cross-sectional survey was administered in five sub-locations in Migori County, Kenya. A total of 4,765 heads of household were surveyed. Multidimensional poverty indices were used to determine the association of poverty with depression using the Patient Health Questionnaire (PHQ-8) depression screening tool. RESULTS: Across the geographic areas surveyed, the overall prevalence of household poverty (deprivation headcount) was 19.4%, ranging from a low of 13.6% in Central Kamagambo to a high of 24.6% in North Kamagambo. Overall multidimensional poverty index varied from 0.053 in Central Kamagambo to 0.098 in North Kamagambo. Of the 3,939 participants with depression data available, 481 (12.2%) met the criteria for depression based on a PHQ-8 depression score ≥10. Poverty showed a dose-response association with depression. CONCLUSIONS: Multidimensional poverty indices can be used to accurately capture poverty in rural Kenya and to characterize differences in poverty across areas. There is a clear association between multidimensional poverty and depressive symptoms, including a dose effect with increasing poverty intensity. This supports the importance of multifaceted poverty policies and interventions to improve wellbeing and reduce depression.
Asunto(s)
Depresión/epidemiología , Pobreza/estadística & datos numéricos , Adulto , Estudios Transversales , Femenino , Humanos , Kenia , Masculino , PrevalenciaRESUMEN
Migori County is located in western Kenya bordering Lake Victoria and has traditionally performed poorly on important health metrics, including child mortality and HIV prevalence. The Lwala Community Alliance is a non-governmental organization that serves to promote the health and well-being of communities in Migori County through an innovative model utilizing community health workers, community committees, and high-quality facility-based care. This has led to improved outcomes in areas served, including improvements in childhood mortality. As the Lwala Community Alliance expands to new programming areas, it has partnered with multiple academic institutions to rigorously evaluate outcomes. We describe a repeated cross-sectional survey study to evaluate key health metrics in both areas served by the Lwala Community Alliance and comparison areas. This will allow for longitudinal evaluation of changes in metrics over time. Surveys will be administered by trained enumerators on a tablet-based platform to maintain high data quality.
Asunto(s)
Composición Familiar , Salud , Características de la Residencia , Factores Sociodemográficos , Humanos , Kenia/epidemiología , Tamaño de la Muestra , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
INTRODUCTION: From the outset of the COVID-19 pandemic, guidance from WHO has promoted social distancing, wearing face masks, frequent hand washing, and staying-at-home as measures to prevent the spread of COVID-19. For many across Africa, compliance can be difficult. The aim of this study was to 1) understand the impact of student's household's ability to comply with COVID-19 mitigation strategies, 2) identify predictors of mitigation strategy compliance, and 3) describe the impact of COVID-19 on household economics, food-security, and mental well-being. MATERIALS AND METHODS: We conducted an email-based survey among current medical and pharmacy students of the University of Liberia College of Health Sciences between July and October 2020. The questionnaire was designed to explore their household's ability to comply with current mitigation strategies, as well as the pandemic´s impact on the student's household's finances and food security. Descriptive statistics were used to delineate demographic characteristics. Logistic regression was used to model factors associated with ability to comply with COVID-19 mitigation strategies, as well as participant's food security. RESULTS: 113 persons responded to the questionnaire. Seventy-six (67â3%) reported income losses as a result of the pandemic, with 93 (82â3%) reporting being "somewhat" or "very worried" about their households' finances. Seventy-seven (68â1%) participants reported food stocks that were sufficient for one-week or less. Forty (35%) participants reported eating less preferred foods or skipping meals in the past week. Overall, 20 participants (19â4%) had a positive depression screen. CONCLUSIONS: Study participants showed mixed results in being able to adhere to national COVID-19 mitigation strategies, with household level stressors experienced around finances and food security. Until Liberia has access to vaccinations for most of its citizens, COVID-19 response measures need to provide social protections that address basic needs (shelter, clothing and food), and which specifically targets food insecurity. Preventative interventions for mental health problems must be incorporated into Liberia's response to the pandemic.
Asunto(s)
COVID-19 , Composición Familiar , Inseguridad Alimentaria/economía , Salud Mental , Pandemias/economía , SARS-CoV-2 , Encuestas y Cuestionarios , Adulto , COVID-19/economía , COVID-19/epidemiología , COVID-19/prevención & control , COVID-19/psicología , Femenino , Seguridad Alimentaria , Humanos , Liberia/epidemiología , MasculinoRESUMEN
Family planning and contraceptive utilization can have significant effects in reducing unplanned pregnancies and improving maternal and child health indicators. We conducted a retrospective cross-sectional study analyzing survey response data within six sub-locations of Migori County, Kenya in 2018 and 2019. We utilize this survey data to estimate both the prevalence of contraceptive uptake and unwanted pregnancies in the study populations, and to examine the potential role that different factors play in meeting related family planning targets. Descriptive statistics were calculated, and multivariable logistic regression was used to model determinants of contraceptive use and reported unplanned pregnancy. A total of 3,642 female heads of household were included. 63% of respondents reported that they currently use some form of contraception, and the prevalence of unplanned pregnancy was 36.7%. Our findings reflect the need for family planning programs to focus interventions on those at highest risk. There is a need for additional research and investigation into community and individual beliefs surrounding family planning in order to ensure that interventions are culturally sensitive and locally responsive.
Asunto(s)
Conducta Anticonceptiva/estadística & datos numéricos , Anticoncepción/estadística & datos numéricos , Anticonceptivos/uso terapéutico , Servicios de Planificación Familiar/organización & administración , Embarazo no Planeado , Adolescente , Adulto , Conducta Anticonceptiva/etnología , Estudios Transversales , Cultura , Composición Familiar , Femenino , Humanos , Kenia/epidemiología , Persona de Mediana Edad , Embarazo , Embarazo no Deseado , Prevalencia , Religión , Estudios Retrospectivos , Encuestas y Cuestionarios , Adulto JovenRESUMEN
BACKGROUND: Bacteremia is a major cause of morbidity and mortality worldwide. Children infected with HIV present with patterns of bacteremia generally associated with poor prognosis. In Mozambique, data on bacteremia are sparce. METHODS: We conducted an observational study of HIV-infected and HIV-exposed uninfected children, aged 0-59 months, hospitalized with fever between April 1, 2016 and February 28, 2019. A single bacterial culture was collected at admission. Descriptive statistics were used to summarize microorganisms detected and antibiotic susceptibility testing. RESULTS: A total of 808 HIV-infected (90%) and HIV-exposed uninfected (10%) children were enrolled. Blood culture positivity was 12% (95% CI: 9.9%-14.4%). Five organisms accounted for most cases: Staphylococcus Aureus (37%), Klebsiella spp (11%), Salmonella spp (11%), Escherichia Coli (9%) and Micrococcus (7%). Antibiotic resistance was common. Nearly 70% of Staphylococcus Aureus were methicillin-resistant and roughly 50% of Klebsiella had ESBL production. CONCLUSION: Community-acquired bacteremia was common in HIV-infected and HIV-exposed uninfected children hospitalized in Mozambique with a febrile illness. High rates of MRSA and ESBL producing organisms has implications for empiric antibiotics utilized in Mozambique. Longitudinal data on the prevalence and antimicrobial resistance patterns of important pathogens are badly needed to guide policy for drug formulary expansion and antibiotic prescription guidelines.
Asunto(s)
Bacteriemia , Infecciones Comunitarias Adquiridas , Infecciones por VIH , Infecciones Estafilocócicas , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Bacteriemia/epidemiología , Niño , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/epidemiología , Fiebre/tratamiento farmacológico , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Humanos , Pruebas de Sensibilidad Microbiana , Mozambique/epidemiología , Infecciones Estafilocócicas/tratamiento farmacológicoRESUMEN
INTRODUCTION: Retention in HIV care is a challenge in Mozambique. Mozambique´s southern provinces have the highest mobility levels of the country. Mobility may result in poorer response to HIV care and treatment initiatives. METHODS: We conducted a cross-sectional survey to explore the impact of mobility on retention for HIV-positive adults on ART presenting to the clinic in December 2017 and January 2018. Survey data were linked to participant clinical records from the HIV care and treatment program. This study took place in Manhiça District, southern Mozambique. We enrolled self-identified migrants (moved outside of Manhiça District ≤12 months prior to survey) and non-migrants, matched by age and sex. RESULTS: 390 HIV-positive adults were included. We found frequent movement: 45% of migrants reported leaving the district 3-5 times over the past 12 months, usually for extended stays. South Africa was the most common destination (71%). Overall, 30% of participants had at least one delay (15-60 days) in ART pick-up and 11% were delayed >60 days, though no significant difference was seen between mobile and non-mobile cohorts. Few migrants accessed care while traveling. CONCLUSION: Our population of mobile and non-mobile participants showed frequent lapses in ART pick-up. Mobility could be for extended time periods and HIV care frequently did not continue at the destination. Studies are needed to evaluate the impact of Mozambique´s approach of providing 3-months ART among mobile populations and barriers to care while traveling, as is better education on how and where to access care when traveling.
Asunto(s)
Infecciones por VIH/mortalidad , Adolescente , Adulto , Instituciones de Atención Ambulatoria , Fármacos Anti-VIH/uso terapéutico , Estudios Transversales , Femenino , Infecciones por VIH/tratamiento farmacológico , Humanos , Masculino , Persona de Mediana Edad , Mozambique , Aceptación de la Atención de Salud , Retención en el Cuidado , Sudáfrica , Adulto JovenRESUMEN
BACKGROUND: The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014-2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country's maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). METHODS: Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible. RESULTS: Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1-3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided. CONCLUSIONS: Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.
Asunto(s)
Anestesia/tendencias , Atención a la Salud/tendencias , Accesibilidad a los Servicios de Salud/tendencias , Fiebre Hemorrágica Ebola/epidemiología , Fiebre Hemorrágica Ebola/terapia , Capacidad de Camas en Hospitales , Anestesia/economía , Atención a la Salud/economía , Accesibilidad a los Servicios de Salud/economía , Capacidad de Camas en Hospitales/economía , Humanos , Liberia/epidemiología , Encuestas y CuestionariosRESUMEN
BACKGROUND: Altered mental status (AMS) is a priority presenting sign that must be assessed in HIV-infected, febrile children, yet diagnosis is difficult in areas with limited diagnostic capacity. Malaria and bacterial meningitis have been reported as the most common causes of AMS in febrile children presenting to the hospital in sub-Saharan Africa. However, in an HIV-infected child, central nervous system manifestations are diverse. METHODS: We conducted a clinical observational study of HIV-infected febrile children, aged 0-59 months, hospitalized in Mozambique and prospectively followed. Within this cohort, a nested study was designed to characterize children admitted with AMS and to assess factors associated with mortality. Univariate and multivariable analysis were performed comparing characteristics of the cohort by AMS status and evaluated demographic and clinical factors by in-hospital mortality outcome. RESULTS: In total, 727 children were enrolled between April 2016 and February 2019, 16% had AMS at admission. HIV-infected, febrile children, who presented with AMS and who had a diagnosis of bacteremia, had a 4-fold increased relative odds of in-hospital mortality, and children who presented with neurologic symptoms on admission had a roughly 8-fold higher odds of in-hospital mortality relative to children without presenting neurologic findings. CONCLUSIONS: Mozambique has a pressing need to expand local diagnostic capacity. Our results highlight the critical need for clinicians to incorporate a broader differential into their potential causes of AMS, and to develop a Ministry of Health approved diagnostic and management algorithm, which is standardly used, to manage patients for whom reliable and relevant diagnostic services are not available.
Asunto(s)
Bacteriemia , Infecciones por VIH , Malaria , Niño , Preescolar , Femenino , Fiebre/epidemiología , Fiebre/etiología , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Humanos , Lactante , Recién Nacido , Masculino , Mozambique/epidemiologíaRESUMEN
This paper explores individual, interpersonal- and household-level factors influencing HIV-related sexual risk behaviour among adolescent girls who participated in an intervention to reduce HIV risk in a rural setting in Mozambique. Twenty-eight adolescent girls ages 13-19, 30 heads of household, and 53 influential men participated in in-depth interviews at two time points. Comparative analysis compared girls who reported reducing risk behaviours over time to girls who did not and identified factors that respondents described as influential to behaviour change. Among the twenty girls self-reporting sexual risk at the first time point, half had reduced these behaviours one year later. Changes in girls' behaviours were contingent upon household- and interpersonal-level factors, particularly households' economic stability and family members' financial support. Future interventions with adolescents in similar settings should evaluate and leverage household and family support to achieve sexual risk reduction.
Asunto(s)
Infecciones por VIH , Pobreza , Adolescente , Adulto , Femenino , Infecciones por VIH/prevención & control , Humanos , Masculino , Mozambique , Asunción de Riesgos , Conducta Sexual , Adulto JovenRESUMEN
Pediatric Lassa fever (LF) usually presents as a nonspecific febrile illness, similar to other endemic diseases in countries like Sierra Leone, where LF is considered to be hyperendemic. The nonspecificity of presentation and lack of research have made it difficult to fully understand best practices for pediatric management. We aim to describe clinical characteristics of hospitalized pediatric patients suspected or diagnosed with LF and assess factors associated with hospital outcomes among those with LF antigen-positive results. We conducted a 7-year retrospective cohort study using routine data for all children younger than 18 years admitted at the Kenema Government Hospital's LF ward. A total of 292 children with suspected or confirmed LF were analyzed. Overall, mortality was high (21%). Children with antigen-positive results had a high case fatality rate of 63% (P < 0.01). In univariate analyses, children who presented with unexplained bleeding (odds ratio [OR]: 3.58; 95% CI: 1.08-11.86; P = 0.040) and confusion (altered sensorium) (OR: 5.37; 95% CI: 1.34-21.48; P = 0.020) had increased odds of death. Abnormal serum levels of alanine aminotransferase (P = 0.001), creatinine (P = 0.004), and potassium (P = 0.003) were associated with increased likelihood of death in these children. Treatment with ribavirin was not significantly associated with survival (P = 0.916). Our findings provide insights into current pediatric LF clinical presentation and management. More evidence-based, high-quality research in creating predictive algorithms of antigen-positivity and hospital outcomes is needed in the management of pediatric LF.