Enhancing and promoting data management and systematic monitoring for an improved HIV/AIDS programs in Addis Ababa, Ethiopia.

BACKGROUND: Ethiopia Population-based HIV Impact Assessment findings showed that in Addis Ababa, only 65.2% of people living with HIV (PLHIV) know their status. We present the enhanced HIV/AIDS data management and systematic monitoring experience in Addis Ababa City Administration Health Bureau (AACAHB). METHODS: AACAHB established a command-post with leadership and technical team members from the health bureau, 10 sub-city health offices, and non-governmental stakeholders. The command-post improved governance, standardized HIV program implementation, and established accountability mechanism. A web-based database was established at each health facility, sub-city, and AACAHB level. Performance was scored (green, ≥75%; yellow, 50-74%; red, < 50%). The command-post reviewed performance on weekly basis. A mentorship team provided a weekly site-level support at underperforming public and private health facilities. At facility level, quality of data on recording tools such as registers, and individual medical records were maintained through continued review, feedback mechanisms and regular consistency check of data. Percentage and 95% confidence interval were computed to compare the improvement in program performance over time. RESULTS: After 6 months of intervention period, the monthly New HIV case finding in 47 health facilities increased from 422 to 734 (1.7 times) and treatment initiation increased from 302 to 616 (2 times). After 6 months, the aggregate scoring for HIV testing at city level improved from yellow to green, HIV case finding improved from red to green, and treatment initiation improved from red to yellow. An increasing trend was noted in HIV positive case finding with statistically significant improvement from 43.4% [95% Confidence Interval: 40.23-46.59%] in May 2019 to 74.9% [95% Confidence Interval: 72.03-77.6%] in September 2019. Similarly, significant improvement was recorded for new HIV treatment from 30.9% [95% Confidence Interval: 28.01-33.94%] in May 2019 to 62.5% [95% Confidence Interval: 59.38-65.6%] in September 2019. CONCLUSIONS: Regular data driven HIV program review was institutionalized at city, sub-city and health facility levels which further improved HIV program monitoring and performance. The performance of HIV case finding and treatment initiation improved significantly via using intensified monitoring, data driven performance review, targeted site-level support based on the gap, and standardized approaches.

Bell's palsy in pregnancy as a prodromal sign of preeclampsia: A report of three cases, pregnancy outcome, and literature review.

Bell's palsy is a less common neurological disorder in the general population. Its occurrence during pregnancy can be used as a predictor of adverse obstetric outcomes including preeclampsia and its complications. We report cases of three pregnant women from Botswana who presented with Bell's palsy in the third trimester coexisting with preeclampsia and multiple complications. One of the patient was a case of maternal near-miss with multiple life threating complications including stage 3 acute kidney injury (AKI) and required hemodialysis. The second and third patients developed Bell`s palsy and preeclampsia at term, management of preeclampsia commenced with immediate delivery resulting in good maternal and neonatal outcome. In all the three patients preeclampsia and Bell`s palsy completely resolved post-delivery. Therefore, new onset Bell's palsy in pregnancy may be used as a prodromal sign of preeclampsia. Such patients deserve close follow up for preeclampsia or gestational hypertension for a better obstetric outcome.

Improvement in tuberculosis infection control practice via technical support in two regions of Ethiopia.

BACKGROUND: Globally recommended measures for comprehensive tuberculosis (TB) infection control (IC) are inadequately practiced in most health care facilities in Ethiopia. The aim of this study was to assess the extent of implementation of TB IC measures before and after introducing a comprehensive technical support package in two regions of Ethiopia. METHODS: We used a quasi-experimental design, whereby a baseline assessment of TB IC practices in 719 health care facilities was conducted between August and October 2013. Based on the assessment findings, we supported implementation of a comprehensive package of interventions. Monitoring was done on a quarterly basis, and one-year follow-up data were collected on September 30, 2014. We used the Student's t-test and chi-squared tests, respectively, to examine differences before and after the interventions and to test for inter-regional and inter-facility associations. RESULTS: At baseline, most of the health facilities (69%) were reported to have separate TB clinics. In 55.2% of the facilities, it was also reported that window opening was practiced. Nevertheless, triaging was practiced in only 19.3% of the facilities. Availability of an IC committee and IC plan was observed in 29.11 and 4.65% of facilities, respectively. Health care workers were nearly three times as likely to develop active TB as the general population. After 12 months of implementation, availability of a separate TB room, TB IC committee, triage, and TB IC plan had increased, respectively, by 18, 32, 44, and 51% (p < 0.001). CONCLUSIONS: After 1 year of intervention, the TB IC practices of the health facilities have significantly improved. However, availability of separate TB rooms and existence of TB IC committees remain suboptimal. The burden of TB among health care workers is higher than in the general population. TB IC measures must be strengthened to reduce TB transmission among health workers.

Vitamin D deficiency among smear positive pulmonary tuberculosis patients and their tuberculosis negative household contacts in Northwest Ethiopia: a case-control study.

BACKGROUND: Vitamin D is a fat-soluble vitamin that increases the immunity against tuberculosis (TB), decreases the re-activation of latent TB and reduces the severity of active TB disease. Epidemiological studies on the prevalence of vitamin D deficiency, and its association with TB showed inconsistent results in different countries. This study was aimed to determine the prevalence of vitamin D deficiency and its association with TB in Northwest Ethiopia. METHODS: A case-control study was conducted among smear positive pulmonary tuberculosis patients and their household contacts without symptoms suggestive of TB. Study participants were recruited at 11 TB diagnostic health facilities in North and South Gondar zones of Amhara region between May 2013 and April 2015. The spot-morning-spot sputum samples and 5 ml blood sample were collected prior to commencing TB treatment for the diagnosis of TB and serum vitamin D assay, respectively. The diagnosis of TB was performed using smear microscopy and GeneXpert. Serum vitamin D level was analyzed using VIDAS 25 OH Vitamin D Total testing kits (Biomerieux, Marcy I'Etoile, France) on mini VIDAS automated immunoassay platform. Vitamin D status was interpreted as deficient (<20 ng/ml), insufficient (20-29 ng/ml), sufficient (30-100 ng/ml) and potential toxicity (>100 ng/ml). RESULTS: Of the total study participants, 134 (46.2%) were vitamin D deficient, and only 56 (19.3%) had sufficient vitamin D level. A total of 59 (61.5%) TB patients and 75 (38.7%) non TB controls were vitamin D deficient. Results of multivariate logistic regression analyses showed a significantly higher vitamin D deficiency among tuberculosis cases (p < 0.001), females (p = 0.002), and urban residents (p < 0.001) than their respective comparison groups. Moreover, age groups of 35-44 (p = 0.001), 45-54 (p = 0.003) and ≥55 (p = 0.001) years had significantly higher vitamin D deficiency compared with age group <15 years. CONCLUSIONS: Vitamin D deficiency is highly prevalent among TB patients and non TB controls in Ethiopia where there is year round abundant sunshine. Study participants with tuberculosis, females, older age groups, and urban residents had significantly higher prevalence of vitamin D deficiency. These findings warrant further studies to investigate the role of vitamin D supplementation in the prevention and treatment of tuberculosis in high TB burden countries like Ethiopia.

Family planning use among women living with HIV: knowing HIV positive status helps - results from a national survey.

BACKGROUND: Women living with HIV continues to encounter unintended pregnancies with a concomitant risk of mother-to-child transmission of HIV infection. Preventing unintended pregnancy among HIV-infected women is one of the strategies in the prevention of new HIV infections among children. The aim of this analysis was to assess the practice of family planning (FP) among HIV-infected women and the influence of women's awareness of HIV positive status in the practice of FP. METHODS: The analysis was made in the Malawi Demographic and Health Survey (DHS) data among 489 non-pregnant, sexually active, fecund women living with HIV. Multiple logistic regression analysis was performed using SPSS software to identify the factors associated with FP use. Adjusted odds ratios (AOR) with 95 % confidence intervals were computed to assess the association of different factors with the practice of family planning. RESULT: Of the 489 confirmed HIV positive women, 184 (37.6 %) reported that they knew that they were HIV positive. The number of women who reported that they were currently using FP method(s) were 251 (51.2 %). The number of women who reported unmet need for FP method(s) were 107 (21.9 %). In the multiple logistic regression analysis, women's knowledge of HIV positive status [AOR: 2.32(1.54, 3.50)], secondary and above education [AOR: 2.36(1.16, 4.78)], presence of 3-4 alive children [AOR: 2.60(1.08, 6.28)] and more than 4 alive children [AOR: 3.03(1.18, 7.82)] were significantly associated with current use of FP. CONCLUSION: Women's knowledge of their HIV-positive status was found to be a significant predictor of their FP practice. Health managers and clinicians need to improve HIV counselling and testing coverage among women of child-bearing age and address the FP needs of HIV-infected women.

Use of Electronic Quality Monitoring Tool and Central Dashboard to Improve Clinical and Programmatic Decisions.

The HIV service quality improvement tool is deployed in 123 health facilities in Ethiopia. The tool uses a central dashboard for visualization and decision making at the health facility and higher levels of the health systems. The dashboard is developed on excel with analytics about HIV testing, case finding, treatment linkage and quality indicators. The dashboard was developed based on the requirements requested during discussions with HIV clinicians and the program team.

Data-Exchange Between Electronic Medical Record and Viral-Load Laboratory Database Towards Improving HIV Care in Ethiopia.

Electronic viral load (VL) Test Ordering and Result Reporting System (ETORRS) was introduced to create data exchange between the existing VL database and the electronic medical record (EMR) system, with the aim of reducing laboratory test results turnaround time (TAT), improving data quality, and supporting timely clinical response for patients with high VL. This use case is an illustrative example of initiating and adopting the principles of health information exchange for a priority health program.

Outbreak investigation of epidemic dropsy in Addis Ababa, Ethiopia:.

BACKGROUND: A 17 year old female patient who presented to a tertiary Hospital in Addis Ababa with bilateral painful leg swelling of two months and shortness of breath, associated with cough and haemoptysis of one week duration was reported to the Ministry of Health and the Addis Ababa Health Bureau. The condition was later detected in 18 individuals from 4 households indicating occurrence of an outbreak of unknown cause in Addis Ababa which lasted during May-July 2008. OBJECTIVE: An outbreak investigation was initiated to identify the cause and prevent further spread, morbidity and mortality. METHODS: Using semi-structured questionnaire, quantitative assessment involving individual cases and affected households was conducted to detect aetiology and risk factors. Unaffected households as well as unaffected members of affected households were also included for comparison purpose. Record review of patients visiting hospitals was also done. Data were collected through house to house visits, and using interview of cases admitted to hospital. Samples of cooking oil were collected for laboratory testing. Data analysis was done using SPSS. RESULTS: A total of 182 patients, 50 (27.5%) males and 132 (72.5%) females, were identified till the outbreak was controlled fully. Age varied from 6-90 years. Death was confirmed in 12 cases, 8 of whom were female. The majority of the patients came from the adjoining Lideta (39.0%) and Kolfe Keranyo (31.9%) subcities. History of illness ranged from less than a week to 12 weeks before presentation. Out of the 106 household members of the 24 affected households identified during the first phase of the investigation, 83 were affected. Most family members who infrequently take meals at home, and children aged 3 years and below were spared. The 21 visited affected households from Kolfe keranyo, Lideta and Bole subcities bought cooking oil produced by a firm in Lideta subcity and all had bought their last supplies in March and April 2008. Samples of cooking food oil taken from this firm and from the affected households were found to have alkaloids of Argemone Mexicana. The number of new cases dropped to zero within 6 weeks after the source was closed. CONCLUSION: The occurrence of bilateral leg swelling in more than one family member of affected households, that bought cooking oil from the same source, sparing the toddlers, and those who infrequently take meals at home, further strengthened by laboratory confirmation of presence of argemone alkaloids in the cooking oil samples taken from the affected households and the common sources led to the diagnosis of the outbreak to be epidemic dropsy.

Maternal risk factors for childhood anaemia in Ethiopia.

A total of 8260 children between the ages of 6-59 months were analyzed to identify the risk factors associated with childhood anaemia in Ethiopia. The overall mean (SD/standard deviation) haemoglobin (Hgb) level among the under-five children was 10.7 (2.2) g/dl and 50.3% were anaemic. Childhood anaemia demonstrated an increasing trend with maternal anaemia levels of mild, moderate and severe anaemia: odds ratio of 1.82, 2.16 and 3.73 respectively (p< 0.01). Children whose mothers had no formal education were 1.38 times more likely to be anaemic (p<0.01). The poorest and poorer wealth index groups had 1.52 and 1.25 increased odds of childhood anaemia respectively (p< 0.01). Childhood anaemia in Ethiopia is a severe public health problem. Maternal anaemia and socio-economic status were found to be associated with anaemia in children. A holistic approach of addressing mothers and children is of paramount importance.

Contraception and intersection with HIV services in 11 high HIV burden sub-Saharan African countries: Results from the population-based HIV Impact Assessment cross-sectional studies conducted from 2015 to 2018.

OBJECTIVE: The United Nations' Sustainable Development Goal 3.7.1 addresses the importance of family planning. The objective of this paper is to provide information on family planning to policymakers to help increase access to contraceptive methods to women in sub-Saharan Africa. METHODS: We analyzed data from the Population-based HIV Impact Assessment studies conducted in 11 sub-Saharan African countries from 2015 to 2018 to assess the relationship between HIV services and family planning. Analyses were restricted to women aged 15-49 years who reported being sexually active within the past 12 months and had data on contraceptive use. RESULTS: Approximately 46.4% of participants reported using any form of contraception; 93.6% of whom used modern contraceptives. Women with a positive HIV status were more likely to use contraceptives (P < 0.0001) than HIV-negative women. Unmet need was higher among women who were confirmed to be HIV-negative in Namibia, Uganda, and Zambia than confirmed to be positive. Women aged 15-19 years used contraception less than 40% of the time. CONCLUSION: This analysis highlights crucial gaps in progress among HIV-negative and young women (aged 15-19 years). To provide access to modern contraception for all women, programs and governments need to focus on women who desire but do not have access to these family planning resources.

Metabolic Control and Determinants Among HIV-Infected Type 2 Diabetes Mellitus Patients Attending a Tertiary Clinic in Botswana.

PURPOSE: We primarily aimed at determining the prevalence of metabolic syndrome and abnormal individual metabolic control variables in HIV-infected participants as compared to HIV-uninfected participants given current concerns. Our secondary objective was to determine the predictors of metabolic syndrome and individual metabolic control variables among the study participants to guide future management. PATIENTS AND METHODS: A descriptive, case-matched cross-sectional study for four months from 15th June 2019 to 15th October 2019 at Block 6 Diabetes Reference Clinic in Gaborone, Botswana. We compared the proportions of metabolic syndrome and individual metabolic control variables based on gender and HIV status by means of bivariate analysis (Chi-squared test or Fisher's exact test) to determine factors associated with metabolic control. A p-value of less than 0.05 was considered statistically significant. RESULTS: Overall, 86% of the study participants were found to have metabolic syndrome by International Diabetes Federation (IDF) criteria with 79.8% among HIV-infected and 89.1% among HIV-negative participants (p-value = 0.018). Older age was significantly associated with metabolic syndrome (p-value = 0.008). Female gender was significantly associated with metabolic syndrome as compared to male gender (P-value < 0.001), and with a statistically significant higher proportion of low HDL-C compared to males (P-value < 0.001). Female participants were significantly more likely to be obese as compared to males (P-value < 0.001). High triglycerides were more common in HIV-infected compared to HIV-negative participants (P-value = 0.004). HIV-negative participants were more likely to be obese as compared to HIV-infected participants (P-value = 0.003). CONCLUSION: Metabolic syndrome is an appreciable problem in this tertiary clinic in Botswana for both HIV-infected and HIV-negative participants. Future prospective studies are warranted in our setting and similar sub-Saharan settings to enhance understanding of the role played by HAART in causing the metabolic syndrome, and the implications for future patient management.

Antibiotic selection pressure and macrolide resistance in nasopharyngeal Streptococcus pneumoniae: a cluster-randomized clinical trial.

BACKGROUND: It is widely thought that widespread antibiotic use selects for community antibiotic resistance, though this has been difficult to prove in the setting of a community-randomized clinical trial. In this study, we used a randomized clinical trial design to assess whether macrolide resistance was higher in communities treated with mass azithromycin for trachoma, compared to untreated control communities. METHODS AND FINDINGS: In a cluster-randomized trial for trachoma control in Ethiopia, 12 communities were randomized to receive mass azithromycin treatment of children aged 1-10 years at months 0, 3, 6, and 9. Twelve control communities were randomized to receive no antibiotic treatments until the conclusion of the study. Nasopharyngeal swabs were collected from randomly selected children in the treated group at baseline and month 12, and in the control group at month 12. Antibiotic susceptibility testing was performed on Streptococcus pneumoniae isolated from the swabs using Etest strips. In the treated group, the mean prevalence of azithromycin resistance among all monitored children increased from 3.6% (95% confidence interval [CI] 0.8%-8.9%) at baseline, to 46.9% (37.5%-57.5%) at month 12 (p = 0.003). In control communities, azithromycin resistance was 9.2% (95% CI 6.7%-13.3%) at month 12, significantly lower than the treated group (p < 0.0001). Penicillin resistance was identified in 0.8% (95% CI 0%-4.2%) of isolates in the control group at 1 year, and in no isolates in the children-treated group at baseline or 1 year. CONCLUSIONS: This cluster-randomized clinical trial demonstrated that compared to untreated control communities, nasopharyngeal pneumococcal resistance to macrolides was significantly higher in communities randomized to intensive azithromycin treatment. Mass azithromycin distributions were given more frequently than currently recommended by the World Health Organization's trachoma program. Azithromycin use in this setting did not select for resistance to penicillins, which remain the drug of choice for pneumococcal infections. TRIAL REGISTRATION: www.ClinicalTrials.gov NCT00322972. Please see later in the article for the Editors' Summary.

Factors Determining Treatment Success in Children with Drug-Sensitive Tuberculosis in Ethiopia: A Three-Year Retrospective Analysis.

This study in the Amhara and Oromia regions of Ethiopia assessed the outcomes of tuberculosis (TB) treatment among children younger than 15 years. Retrospective data were collected on treatment outcomes and their determinants for children with TB for the cohorts of 2012-2014 enrolled in 40 hospitals and 137 health centers. Chi-square tests, t-tests, and logistic regression were used for the analysis. Of 2,557 children registered, 1,218 (47.6%) had clinically diagnosed pulmonary TB, 1,100 (43%) had extrapulmonary TB, and 277 (8.9%) had bacteriologically confirmed TB. Among all cases, 2,503 (97.9%) were newly diagnosed and 178 (7%) were HIV positive. Two-thirds of the children received directly observed treatment (DOT) in health centers and the remaining one-third, in hospitals. The treatment success rate (TSR) was 92.2%, and the death rate was 2.8%. The childhood TSR was high compared with those reported in focal studies in Ethiopia, but no national TSR report for children exists for comparison. Multivariate analysis showed that being older-5-9 years (adjusted odds ratio [AOR], 95% CI: 2.53, 1.30-4.94) and 10-14 years (AOR, 95% CI: 2.71, 1.40-5.26)-enrolled in DOT in a health center (AOR, 95% CI: 2.51, 1.82-3.48), and HIV negative (AOR, 95% CI: 1.77, 1.07-2.93) were predictors of treatment success, whereas underdosing during the intensive phase of treatment (AOR, 95% CI: 0.54, 0.36-0.82) was negatively correlated with treatment success. We recommend more research to determine if intensive monitoring of children with TB, dosage adjustment of anti-TB drugs based on weight changes, and training of health workers on dosage adjustment might improve treatment outcomes.

Adjustments of medication dosages in patients with renal impairment in Botswana; findings and implications to improve patient care.

Background and aims: Medication dosage adjustments for renally impaired patients have not been studied in Botswana. This study was conducted to determine prescribing practices among patients with renal impairment in medical wards to improve future patient care.Methods: We conducted a retrospective study involving medical charts of patients admitted at a tertiary level hospital in Gaborone Botswana. Study participants included all patients admitted between August and October 2016 who were hospitalized for ≥24 h. 'Drug prescribing in renal failure: dosing guidelines for adults and children'. was used to determine the extent of dosage adjustments. A logistic regression model was used to assess which patient factors were associated with inappropriate dosage adjustment.Results: Twenty-nine percent (233/804) of patients had renal impairment. Of these, 184 patients with renal impairment were included in the final analysis. There were 1143 prescription entries, of which 20.5% (n = 234) required dosage adjustment for renal function but only 45.7% (n = 107) were adjusted correctly. Of note, 112 patients were prescribed at least one drug that required dosage adjustment and only 30.4% (n = 34) patients had all of their medications appropriately adjusted. Patient factors associated with inappropriate dosage adjustment included a higher number of medicines being prescribed. Mortality among patients with renal impairment was independently associated with higher scores of the Charlson comorbidity index and hospital stay duration of 1-7 days.Conclusion: The renal function status of patients was not sufficiently taken into account when prescribing medicines especially in patients with severely impaired kidney function in Botswana. Continuous medical education needs to be encouraged to address this, which is being implemented. We will be following this up in future studies.

Knowledge, attitudes, and practices related to TB among the general population of Ethiopia: Findings from a national cross-sectional survey.

INTRODUCTION: Ethiopia is among the high-burden countries for tuberculosis (TB), TB/HIV, and drug-resistant TB. The aim of this nationwide study was to better understand TB-related knowledge, attitudes, and practices (KAPs) and generate evidence for policy and decision-making. MATERIALS AND METHODS: We conducted a cross-sectional TB KAP survey in seven regions and two city administrations of Ethiopia. Eighty kebeles (wards) and 40 health centers were randomly selected for the study. Using systematic sampling, 22 households and 11 TB patients were enrolled from each selected village and health center, respectively. Variables with a value of p = < 0.25 were included in the model for logistic regression analysis. RESULTS: Of 3,503 participants, 884 (24.4%), 836 (24.1%), and 1,783 (51.5%) were TB patients, families of TB patients, and the general population, respectively. The mean age was 34.3 years, and 50% were women. Forty-six percent were heads of households, 32.1% were illiterate, 20.3% were farmers, and 19.8% were from the lowest quintile. The majority (95.5%) had heard about TB, but only 25.8% knew that TB is caused by bacteria. Cough or sneezing was reported as the commonest means of TB transmission. The majority (85.3%) knew that TB could be cured. Men, better-educated people, and TB patients and their families have higher knowledge scores. Of 2,483 participants, 96% reported that they would go to public health facilities if they developed TB symptoms. DISCUSSION: Most Ethiopians have a high level of awareness about TB and seek care in public health facilities, and communities are generally supportive. Inadequate knowledge about TB transmission, limited engagement of community health workers, and low preference for using community health workers were the key challenges. CONCLUSIONS: Given misconceptions about TB's causes, low preference for use of community health workers, and inadequate engagement, targeted health education interventions are required to improve TB services.

Determinants of glycemic control among diabetes mellitus patients in a tertiary clinic in Gaborone, Botswana: findings and implications.

BACKGROUND AND AIMS: Glycemic control among patients with diabetes mellitus is associated with a marked reduction of both macrovascular and microvascular complications; however, glycemic control remains an elusive goal worldwide. The aim of this study was to determine factors associated with glycemic control among patients attending a tertiary clinic in Botswana as limited information to date. METHODS: Cross-sectional study in a tertiary clinic in Gaborone, Botswana. Patients were recruited between 21 July 2015 and 21 September 2015. The majority of the randomly recruited patients (368/380-96.8%) had documentation of glycemic control (HbA1c) within three months of study recruitment and were subsequently included in the analysis. Glycemic control was categorized as desirable, suboptimal and poor if HbA1c was <7%, 7-9% and >9%, respectively. Data were analyzed using SPSS for descriptive statistics including both bivariate and multinomial logistic regression. A value of p < 0.05 was considered statistically significant. RESULTS: The analyzed study population consisted of 258/368 (70.1%) females with a mean age (SD) of 56.7 ± 13.6 years. Means (SDs) for diabetes duration and glycated hemoglobin were 7.2 ± 7.1 years and 7.97 ± 2.02%, respectively. Of the 368 patients, 136 (36.95%) and 132/368 (35.86%) had desirable and suboptimal glycemic control, respectively. Older age, attending the clinic for more or equal to 3 years and not being on insulin were associated with both desirable and suboptimal glycemic control whereas duration of diabetes between 5 and 10 years was associated with poor glycemic control. CONCLUSIONS: The majority of patients had poor glycemic control. Older age and not being on insulin were associated with better glycemic control. The fact that patients on insulin had poor glycemic control calls for more research to determine the timing of insulin initiations and dosing schedule factors as these will help to improve overall glycemic control in Botswana and elsewhere.

Management of post abortion complications in Botswana -The need for a standardized approach.

BACKGROUND: Post abortion complications are the third leading cause of maternal death after hemorrhage and hypertension in Botswana where abortion is not legalized. This study aimed at assessing the management of post abortion complications in Botswana. METHODS: A retrospective study was conducted at four hospitals in Botswana in 2014. Socio-demographic, patient management and outcomes data were extracted from patients' medical records. Descriptive statistics and chi-square test were used to analyze and present the data. RESULT: A total of 619 patients' medical records were reviewed. The duration of hospital stay prior to uterine evacuation ranged from less than an hour to 480 hours. All the patients received either prophylactic or therapeutic antibiotics. Use of parenteral antibiotics was significantly associated with severity of abortion, second trimester abortion, use of blood products and the interval between management's decision and uterine evacuation. Uterine evacuation for retained products of conception was achieved by metallic curettage among 516 (83.4%) patients and by vacuum aspiration in 18 (2.9%). At all the study sites, Misoprostol or Oxytocin were used concurrently with surgical evacuation of the uterus. None use of analgesics or anesthetics in the four hospitals ranged between 12.4% to 28.8%. CONCLUSION: There is evidence of delayed patient care and prolonged hospital stay. Metallic curette was the primary method used for uterine evacuation across all the facilities. Pain management and antibiotics use was not standardized. A protocol has to be developed with the aim of standardizing post abortion care.

Use of indicators of standards of care to improve tuberculosis program management in Ethiopia.

BACKGROUND: Systematic monitoring of health programs and on-site mentoring of health workers are essential for the success of health care. This operations research was designed to measure the effectiveness of a new mentorship and supervisory tool for supervisors. METHODS: In 2011 the Help Ethiopia Address the Low TB Performance (HEAL TB) Project used WHO or national TB indicators as standards of care (SOC) for baseline assessment, progress monitoring, gap identification, assessment of health workers' capacity-building needs, and data quality assurance. Cut-off points were selected for poor, average, and best performers for each indicator. In this analysis we present results from 10 zones (of 28) in which 1,165 health facilities were supported from 2011 through 2015. Other zones were excluded from the analysis because they entered the project later. The data were collected by trained mentors/supervisors and entered into Microsoft Excel. We used rates and ratios to show the impact of the intervention. RESULTS: The improvement in the median composite score of 13 selected major indicators (out of 22) over four years was significant (p = 0.000). The proportion of health facilities with 100% data accuracy for all forms of TB was 55.1% at baseline and reached 96.5%. In terms of program performance, the TB cure rate improved from 71% to 91.1%, while the treatment success rate increased from 88% to 95.3%. In the laboratory area, where there was previously no external quality assurance (EQA) for sputum microscopy, 1,165 health facilities now have quarterly EQA, and 96.1% of the facilities achieved a ≥ 95% concordance rate in blinded rechecking. CONCLUSION: The SOC approach for supervision was effective for measuring progress, enhancing quality of services, identifying capacity needs, and serving as a mentorship and an operational research tool.

Prevalence of chronic kidney disease using estimated glomerular filtration rate among diabetes patients attending a tertiary clinic in Botswana.

OBJECTIVES: Diabetes mellitus (DM) is one of the most common contributors of chronic kidney disease (CKD). The epidemiology of CKD, a concern among patients with DM, has not been studied in Botswana. Consequently, the objective of this study was to estimate its prevalence among these patients in Botswana to provide future guidance to both government personnel and physicians. METHODS: Observational cross-sectional study in a leading clinic in Botswana. Demographic and clinical data were obtained from patients through interviews and from their notes using a standard questionnaire. The study was conducted from July to October 2015. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet for Renal Disease equation. CKD was defined as an eGFR < 60 ml/min/1.73 m2. Multivariable logistic regression analyses were performed to assess the associations between CKD and potential factors. RESULTS: The mean age and duration of DM among study participants were 54.67 years (range 21-92 years) and 5.0 years, respectively. Over half, i.e. 213/370 (57.6%) and 232/370 (62.7%), had an average blood pressure greater than 140/90 mmHg and poor glycemic control (HbA1c > 7%), respectively. 31/370 patients (8.4%) had CKD. However, only 18/370 (4.9%) had a diagnosis of CKD documented in their charts. Age, level of education, and duration of diabetes were independently associated with CKD. CONCLUSION: The prevalence of CKD by estimated eGFR was low compared to most previous studies. However, half of patients with CKD are not documented resulting in the potential for prescription errors and drug toxicity. A substantial number of our patients had uncontrolled hypertension and poor glycemic control. Older age, low level of education and longer duration of DM were associated with CKD. There is a need to carry out prospective studies to determine the association and role of glycemic and blood pressure control in CKD causation among patients with DM in Botswana.

Comparison of the yield of tuberculosis among contacts of multidrug-resistant and drug-sensitive tuberculosis patients in Ethiopia using GeneXpert as a primary diagnostic test.

OBJECTIVES: This study compared the yield of tuberculosis (TB) among contacts of multidrug-resistant tuberculosis (MDR-TB) index cases with that in drug-sensitive TB (DS-TB) index cases in a program setting. METHODS: A comparative cross-sectional study was conducted among contacts of sputum smear-positive new DS-TB index cases and MDR-TB index cases. After contacts were screened, GeneXpert was used for the diagnosis of TB. RESULTS: The study included 111 MDR-TB and 119 DS-TB index cases. A total of 340 and 393 contacts of MDR-TB and DS-TB index cases, respectively, were traced, of whom 331 among MDR-TB contacts and 353 among DS-TB contacts were screened. There were 20 (6%) presumptive TB cases for MDR-TB contacts and 41 (11%) for DS-TB contacts. The prevalence of TB among MDR-TB contacts was 2.7% and among DS-TB contacts was 4.0%. The majority of the MDR-TB contacts diagnosed with TB had MDR-TB; the reverse was true for DS-TB. CONCLUSIONS: The yield of TB among contacts of MDR-TB and DS-TB patients using GeneXpert was high as compared to the population-level prevalence. The likelihood of diagnosing rifampicin-resistant TB among contacts of MDR-TB index cases was higher in comparison with contacts of DS-TB index cases. The use of GeneXpert in DS-TB contact investigation has the added advantage of diagnosing rifampicin-resistant TB cases when compared to the use of the nationally recommended acid-fast bacillus (AFB) microscopy for DS-TB contact investigation.