Why are IPTp coverage targets so elusive in sub-Saharan Africa? A systematic review of health system barriers.

BACKGROUND: Use of intermittent preventive treatment (IPTp) is a proven cost-effective intervention for preventing malaria in pregnancy. However, despite the roll-out of IPTp policies across Africa more than ten years ago, utilization levels remain low. This review sought to consolidate scattered evidence as to the health system barriers for IPTp coverage in the continent. METHODS AND FINDINGS: Relevant literature from Africa was systematically searched, reviewed and synthesized. Only studies containing primary data were considered. Studies reveal that: (i) poor leadership and governance contribute to slow decentralization of programme management, lack of harmonized guidelines, poor accountability mechanisms, such as robust monitoring and evaluation systems; (ii) low budgetary allocation towards policy implementation slows scale-up, while out-of-pocket expenditure deters women from seeking antenatal services that include IPTp; (iii) there are rampant human resource challenges including low staff motivation levels attributed to such factors as incorrect knowledge of IPTp recommendations and inadequate staffing; (iv) implementation of IPTp policies is hampered by prevailing service delivery barriers, such as long waiting time, long distances to health facilities and poor service provider/client relations; and (v) drug stock-outs and poor management of information and supply chains impair sustained availability of drugs for IPTp. CONCLUSIONS: For successful IPTp policy implementation, it is imperative that malaria control programmes target health system barriers that result in low coverage and hence programme ineffectiveness.

Safety monitoring of artemisinin combination therapy through a national pharmacovigilance system in an endemic malaria setting.

BACKGROUND: The National Malaria Control Programme in Senegal, introduced since 2006, artemisinin-based combination therapy (ACT administration) for the treatment of uncomplicated malaria cases. In this framework, an anti-malarial pharmacovigilance plan was developed and implemented in all public health services. This study investigated the occurrence of Adverse Drug Events (ADEs) after ACT. METHODS: The study was conducted between January 2007 and December 2009. It was based on spontaneous reports of ADEs in public health facilities. Data on patient demographic characteristics, dispensing facility, adverse signs and symptoms and causality were collected from a total of 123 patients. RESULTS: The age range of these patients was six months to 93 years with a mean of 25.9 years. Of the reported symptoms, 46.7% were related to the abdomen and the digestive system. Symptoms related to the nervous system, skin and subcutaneous tissue, circulatory and respiratory systems and general symptoms and signs were 7%, 9.7%, 3.5% and 31.3%, respectively. Causality results linked 14.3% of symptoms to Falcimon® (Artesunate-Amodiaquine) with certainty. Effects were classified as mild and severe in 69.1% and 7.3% of cases respectively while 23.6% were serious. All patients with serious ADEs were hospitalized. One death was reported in a patient who had taken 24 pills at once. CONCLUSION: These results confirm the need to develop and implement pharmacovigilance systems in malaria endemic countries in order to monitor the safety of anti-malarial treatments.

Pattern of hypertensive kidney disease in a black Kenyan population.

BACKGROUND: Hypertensive kidney disease is a major cause of morbidity and mortality. Its pattern displays geographical and ethnic variations. Data on these patterns are important for informing management and prevention strategies, but on Kenyans such data are scarce. OBJECTIVE: By means of a retrospective study at Kenyatta National Hospital, Nairobi, we aimed to describe the pattern of hypertensive kidney disease in a black Kenyan population. METHODS: Records of hypertensive patients who had impaired kidney function between January 2000 and December 2010 were examined for mode of diagnosis, age, gender, comorbid factors, treatment and outcome. Data were analyzed using the Statistical Package for Social Sciences, version 16.0 for Windows, and are presented using tables and bar charts. RESULTS: A total of 114 cases (72 males, 42 females) were analyzed. The mean age was 42.7 years (range 12-83), peaking at 51-70 years. The male to female ratio was 1.7:1. Comorbid factors included left ventricular hypertrophy (21.1%), congestive heart failure (15.8%), alcohol (11.4%), cerebrovascular accidents, smoking and retinopathy (10.5% each). Multiple comorbid factors were present in 8.8% of the cases. The majority (52.6%) of the patients survived on hemodialysis, 8.8% underwent successful renal transplant and 22.8% died. CONCLUSION: Hypertensive kidney disease affects all age groups, males more than females. It is commonly associated with other cardiovascular conditions and carries a high morbidity. Vigilant control of blood pressure is recommended.

Pulmonary thromboembolism in an East African tertiary referral hospital.

Pulmonary thromboembolism (PTE) is a frequent cause of mortality in Kenya, but its characteristics are hardly reported in Subsaharan Africa. To describe the pattern of PTE among black Africans, in a Kenyan referral hospital. Retrospective study at Kenyatta National Hospital (KNH), Nairobi, Kenya. Records of patients seen between January 2005 and December 2009 were examined for mode of diagnosis, comorbidities, age, gender, treatment and outcome. Data were analyzed using SPSS version 15.0 and are presented in tables and bar charts. One hundred and twenty-eight (60 male; 68 female) cases were analyzed. Diagnosis was made by clinical evaluation, a Well's score of >4.0, high D-dimer levels and ultrasound demonstration of a proximal deep venous thrombosis (DVT, 35.9%), lung spiral computer tomography (CT, 50%), multidetector CT (7.8%) and angiography (6.3%). Most frequent comorbidities included DVT (36%); hypertension (18.8%); pulmonary tuberculosis (PTB, 12.5%); HIV infection (10.9%), pueperium, diabetes mellitus and cigarette smoking (9.4% each). Mean age was 40.8 years (range 5-86 years) with a peak between 30 and 50 years. Over 46% of patients were aged 40 years and less. Male:female ratio was 1:1.13. All the patients were treated with anticoagulants and thrombolytics with only one having embolectomy. Ninety-two patients (71.9%) recovered, 18.8% of them with cor pulmonale, while 28.1% died. PTE is not uncommon in Kenya. It affects many individuals below 40 years without a gender bias, and carries high morbidity and mortality. Associated comorbidities include venous thrombosis, lifestyle conditions and communicable diseases. Control measures targeting both are recommended.

Pattern of congestive heart failure in a Kenyan paediatric population.

BACKGROUND: Heart failure in children is a common cause of morbidity and mortality, with high socio-economic burden. Its pattern varies between countries but reports from Africa are few. The data are important to inform management and prevention strategies. OBJECTIVE: To describe the pattern of congestive heart failure in a Kenyan paediatric population. METHODS: This was a retrospective study done at Kenyatta National Hospital, Nairobi Kenya. Records of patients aged 12 years and younger admitted with a diagnosis of heart failure between January 2006 and December 2010 were examined for mode of diagnosis, age, gender, cause, treatment and outcome. Data were analysed using the Statistical Programme for Social Scientists version 16.0 for windows, and presented in tables, bar and pie charts. RESULTS: One hundred and fifty-eight cases (91 male, 67 female) patients' records were analysed. The mean age was 4.7 years, with a peak at 1-3 years. The male: female ratio was 1.4:1. All the cases were in New York Heart Association (NYHA) class II-IV. Evaluation of infants was based on the classification proposed by Ross et al. (1992). Diagnosis was made based on symptoms and signs combined with echocardiography (echo) and electrocardiography (ECG) (38%); echo alone (12.7%); ECG, echo and chest X-ray (CXR) (11.4%); and ECG alone (10.8%). The underlying cause was established on the basis of symptoms, signs, blood tests, CXR, echo and ECG results. Common causes were infection (22.8%), anaemia (17.1%), rheumatic heart disease (14.6%), congenital heart disease (13.3%), cardiomyopathy (7.6%), tuberculosis and human immunodeficiency virus (6.9% each); 77.9% of patients recovered, 13.9% after successful surgery, and 7.6% died. CONCLUSION: Congestive heart failure is not uncommon in the Kenyan paediatric population. It occurs mainly before five years of age, and affects boys more than girls. The majority are due to infection, anaemia, and rheumatic and congenital heart diseases. This differs from those in developed countries, where congenital heart disease and cardiomyopathy predominate. The majority of children usually recover. Prudent control of infection and correction of anaemia are recommended.

The place of knowledge management in influencing lasting health change in Africa: an analysis of AMREF's progress.

INTRODUCTION: AMREF (African Medical and Research Foundation) developed a Knowledge Management Strategy that focused on creating, capturing and applying health knowledge to close the gap between communities and health systems in Africa. There was need to identify AMREF's current Knowledge Management implementation status, problems and constraints encountered after two years of enforcement of the strategy and suggest the way forward. METHODS: This study was conducted between October 2011 and February 2012. Quantitative data on number and foci of AMREF research publications were collected using a questionnaire. Focus group discussions and in-depth interviews were used to gather data on explanations for the trend of publications and the status of the implementation of the 2010-2014 Knowledge Management Strategy. Quantitative data was analysed using SPSS computer software whereas content analysis of themes was employed on qualitative data. RESULTS: Between 1960 and 2011, AMREF produced 257 peer reviewed publications, 158 books and manuals and about 1,188 technical publications including evaluations, guidelines and technical reports. However, the numbers of publications declined from around the year 2000. Large quantities of unpublished and unclassified materials are also in the custody of Heritage. Barriers to Knowledge Management included: lack of incentives for documentation and dissemination; limited documentation and use of good practices in programming; and superficial attention to results or use of evidence. CONCLUSION: Alternative ways of reorganizing Knowledge Management will enable AMREF to use evidence-based knowledge to advocate for appropriate changes in African health policies and practices.

Cardiovascular causes of death in an east African country: an autopsy study.

BACKGROUND: The spectrum of cardiovascular diseases varies between countries. Data from east Africa is scarce, but important in formulating disease management strategies. The aim of this study was to describe the spectrum of cardiovascular causes of death in Kenya. METHODS: One hundred and thirty four autopsy cases of cardiovascular related deaths examined at the Department of Human Anatomy, University of Nairobi, from December 2005 to November 2009 were analyzed for disease type, age and gender distribution. Only cases in which cardiovascular disease was the most likely cause of death were included. Data was analyzed using SPSS version 15.0 for Windows and presented using tables and bar graphs. RESULTS: Cardiovascular causes comprised 13.2% of all autopsy cases. Common conditions included myocardial infarction (18.7%), cardiomyopathy (17.2%), subarachnoid hemorrhage (15.7%), pulmonary thromboembolism (14.2%), ruptured aortic aneurysm (11.2%) and hypertensive heart disease (9.0%). Infective pericarditis and rheumatic heart disease comprised 7.5% and 6.7%, respectively. Mean age was 50.4 years, peaking at 40-60 years, with 56.7% aged 50 years and younger. Male: female ratio was 2.7:1. CONCLUSIONS: Cardiovascular disease contributes more than 13% of overall mortality in Kenya. Myocardial infarction is the commonest, while rheumatic heart disease is the rarest. It is predominantly male and mainly affects those aged under 50 years. This suggests that non-communicable diseases, while predominant, overlap with infectious conditions as causes of cardiovascular mortality. A search for, and the prevention of, risk factors, combined with prudent management of infection, are recommended.