Cryptococcosis in Africa: What the data tell us.

Cryptococcosis is a neglected tropical disease and the main cause of fungal-related deaths in HIV-positive persons in Africa. It is an AIDS-defining illness that has almost surpassed tuberculosis (TB) in mortality despite wide coverage with antiretroviral therapy. What is known about the cryptococcosis burden in Africa is from estimations based on data from a few studies on the infection burden and associated complications. Consequently, the projected implications of cryptococcosis in Africa have been based on these estimations. This systematic review is aimed at providing unique and up-to-date data on the burden of cryptococcosis in Africa using published hospital-based research data on cryptococcosis in HIV infected and uninfected persons. The review also focused on providing temporal data on the availability of diagnostic and therapeutic options for cryptococcosis in Africa. From our results, about 40 948 cases of cryptococcosis were reported in Africa from 1969 to 2021, and the highest prevalence of cryptococcosis was from southern Africa. The most isolated species was Cryptococcus neoformans 42.4% (17 710/41 801) and only 1.3% (549/41 801) isolates were C. gattii. C. neoformans (serotype A) VN I 64.5% (918/1522) was the most prevalent serotype in Africa, while C. gattii (serotype C) VG IV was thought to pose a huge danger. However, C. neoformans (serotype A) VN I continued to be the major threat in Africa. Due to the limited availability of molecular typing methods and the widespread use of culture, direct microscopy, and serological techniques for diagnosis, 23 542 isolates were uncharacterised. Amphotericin B and flucytosine combination therapy is highly recommended for treatment of cryptococcal meningitis. However, these drugs are expensive and remain largely unavailable in most African countries. Amphotericin B requires laboratory facilities to monitor for toxicity. Although fluconazole monotherapy is the readily available treatment option for cryptococcosis, drug resistance, and high mortality have been recorded in majority of cases in Africa. The lack of awareness and paucity of published data on cryptococcosis are likely to have contributed to the underestimation of cases in Africa and led to underprioritisation of this important disease.

Cryptococcosis is a neglected tropical disease that manifests greatly in immunocompromised persons especially those with HIV infection. Our data show that managing cryptococcosis will require an integrated multidisciplinary approach that should include the utilisation of cryptococcal antigen (CrAg) testing, which is highly sensitive and cost-effective for diagnosing this disease.

The clinical spectrum of aspergillosis in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. In this review, we present the clinical spectrum and pathogenesis of syndromes caused by Aspergillus in COPD namely invasive aspergillosis (IA), community-acquired Aspergillus pneumonia, chronic pulmonary Aspergillosis and Aspergillus sensitisation. Some of these entities are clearly linked to COPD, while others may coexist, but are less clearly liked directly to COPD. We discuss current uncertainties as these pertain to IA in COPD cohorts and explore areas for future research in this field.

Fighting female genital mutilation/cutting (FGM/C): towards the endgame and beyond.

Despite the criminalization of the practice by numerous laws and international treaties in most countries concerned, female genital mutilation/cutting (FGM/C), although on the decline overall, is stagnating or tending to increase in some parts Africa. This relative failure in the fight against FGM/C could be explained from an institutional perspective. Although these struggles affect the regulatory mechanisms, which include laws, they hardly touch the normative mechanisms, which constitute the set of values deemed socially acceptable by a society, and the cultural and cognitive mechanisms, which are the manifestations of the ideologies or beliefs of a group. The naming of FGM/C among certain ethnic groups, which is part of the normative character of the social institution, rather valorizes them and makes uncut girls/women feel "dirty" or "unfit". In these communities, women who have undergone FGM/C are viewed by society as women of honour while uncut girls are perceived as promiscuous and victims of mockery, rejection, or exclusion by the community. In addition, since excision ceremonies and rituals are exclusively reserved for women, many see them as a way of freeing themselves from the rules of patriarchy and male domination that are omnipresent in the societies concerned. Informal mechanisms such as the use of witchcraft, gossip, and beliefs related to the supernatural power of the excisors underpin the cultural-cognitive nature of FGM/C practice. As a result, many families are reluctant to challenge the cutters. The fight against FGM/C can be more effective by addressing the normative and cultural-cognitive roots that form the basis for its perpetuation. This can be achieved by avoiding moralizing the practice, involving those who resist the practice in a context of high prevalence, known as "positive deviants," and using productive methods from the societies concerned. This will create a social environment in which FGM/C is increasingly perceived as less favourable and will ultimately allow for a gradual reform of the normative and cultural-cognitive character of societies that practice FGM/C. Education of women and social mobilisation are critical tools which can act as powerful levers in shifting attitudes about FGM/C.

Recent advances and challenges in the early diagnosis and management of invasive fungal infections in Africa.

Invasive fungal infections are a serious concern globally, especially in African settings which are typified by poorly funded and fragile healthcare systems. Low performance diagnostics, limited therapeutics and poor societal awareness of invasive fungal infections are some of the perennial challenges which have contributed to the unacceptably high death rates from these serious infections. However, recent advances have been recorded in fungal diagnostics and therapeutics development. Research into the development of vaccines to prevent fungal disease is beginning to yield promising results. Here we highlight key successes recorded and gaps in this journey and argue that national governments and relevant stakeholders need to do more to prioritise invasive fungal infections. Pragmatic and context-specific measures are proposed to mitigate the peculiar challenges Africa faces in tackling invasive fungal infections.

One country, two crises: what Covid-19 reveals about health inequalities among BAME communities in the United Kingdom and the sustainability of its health system?

There has been mounting evidence of the disproportionate involvement of black, Asian and minority ethnic (BAME) communities by the Covid-19 pandemic. In the UK, this racial disparity was brought to the fore by the fact that the first 11 doctors to die in the UK from Covid-19 were of BAME background. The mortality rate from Covid-19 among people of black African descent in English hospitals has been shown to be 3.5 times higher when compared to rates among white British people. A Public Health England report revealed that Covid-19 was more likely to be diagnosed among black ethnic groups compared to white ethnic groups with the highest mortality occurring among BAME persons and persons living in the more deprived areas. People of BAME background account for 4.5% of the English population and make up 21% of the National Health Service (NHS) workforce. The UK poverty rate among BAME populations is twice as high as for white groups. Also, people of BAME backgrounds are more likely to be engaged in frontline roles. The disproportionate involvement of BAME communities by Covid-19 in the UK illuminates perennial inequalities within the society and reaffirms the strong association between ethnicity, race, socio-economic status and health outcomes. Potential reasons for the observed differences include the overrepresentation of BAME persons in frontline roles, unequal distribution of socio-economic resources, disproportionate risks to BAME staff within the NHS workspace and high ethnic predisposition to certain diseases which have been linked to poorer outcomes with Covid-19. The ethnoracialised differences in health outcomes from Covid-19 in the UK require urgent remedial measures. We provide intersectional approaches to tackle the complex racial disparities which though not entirely new in itself, have been often systematically ignored.

Globalisation in the time of COVID-19: repositioning Africa to meet the immediate and remote challenges.

The COVID-19 pandemic has ushered in a new climate of uncertainty which is fuelling protectionism and playing into nationalist narratives. Globalisation is under significant threat as governments scramble to reduce their vulnerability to the virus by limiting global trade and flows of people. With the imposition of border closures and strict migration measures, there have been major disruptions in Africa's global supply chains with adverse impacts on employment and poverty. The African economies overly reliant on single export-orientated industries, such as oil and gas, are expected to be severely hit. This situation is further aggravated by tumbling oil prices and a lowered global demand for African non-oil products. The agricultural sector, which should buffer these shocks, is also being affected by the enforcement of lockdowns which threaten people's livelihoods and food security. Lockdowns may not be the answer in Africa and the issue of public health pandemic response will need to be addressed by enacting context-specific policies which should be implemented in a humane way. In addressing the socioeconomic impact of COVID-19 on African nations, we argue that governments should prioritize social protection programmes to provide people with resources to maintain economic productivity while limiting job losses. International funders are committing assistance to Africa for this purpose, but generally as loans (adding to debt burdens) rather than as grants. G20 agreement so suspend debt payments for a year will help, but is insufficient to fiscal need. Maintaining cross-border trade and cooperation to continue generating public revenues is desirable. New strategies for diversifying African economies and limiting their dependence on external funding by promoting trade with a more regionalised (continental) focus as promoted by the African Continental Free Trade Agreement, while not without limitations, should be explored. While it is premature to judge the final economic and death toll of COVID-19, African leaders' response to the pandemic, and the support they receive from wealthier nations, will determine its eventual outcomes.

An evaluation of nebulised amphotericin B deoxycholate (Fungizone® ) for treatment of pulmonary aspergillosis in the UK National Aspergillosis Centre.

Antifungal treatment options for allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) are largely limited to itraconazole based on the outcome of randomised controlled trials. It is unclear if nebulised amphotericin B deoxycholate (Fungizone® ) is a viable therapeutic option. We evaluated the safety and efficacy of nebulised Fungizone® in the long-term treatment of various forms of pulmonary aspergillosis. We assessed the records of 177 patients with various forms of pulmonary aspergillosis attending the National Aspergillosis Centre in Manchester who had received Fungizone® . Patients first received a challenge test with nebulised Fungizone® in hospital with spirometry pre/post-Fungizone® and nebulised salbutamol given pre-Fungizone® . Tolerability and changes in Aspergillus IgE, Aspergillus IgG and total IgE were evaluated. Sixty-six per cent (117/177) were able to tolerate the test dose of Fungizone® and in all cases, the reason for discontinuation of the first test dose was worsening breathlessness. Twenty six (21%) stopped therapy within 4-6 weeks, and the commonest reason cited for discontinuation of therapy was increased breathlessness, hoarseness and cough. Eighteen (10.2%) patients continued the Fungizone® for >3 months of which 5 (27.8%) recorded an improvement in total IgE, Aspergillus-specific IgE and Aspergillus IgG. Eleven had ABPA, four had SAFS, two had Aspergillus bronchitis and one had Aspergillus sensitisation with cavitating nodules. Among these 18 patients, sputum fungal culture results went from positive to negative in five patients, became positive in one patient, remained positive in three patients, and remained negative in seven patients. Nebulised Fungizone® appears to be a poorly tolerated treatment for pulmonary Aspergillosis with high dropout rates. There appears to be both clinical and serological benefits following sustained treatment with nebulised Fungizone® in some patients.

Micafungin may be safely administered as outpatient parenteral antimicrobial therapy for chronic pulmonary aspergillosis.

BACKGROUND: Intravenous micafungin has been reported as a treatment alternative in patients with chronic pulmonary aspergillosis (CPA) where long-term oral triazole therapy is unfeasible. OBJECTIVES: We evaluated the safety and efficacy of micafungin administered via the outpatient parenteral antimicrobial therapy (OPAT) service for the treatment of CPA. METHODS: We included all CPA patients who received micafungin via OPAT between April 2016 and March 2018. Data on adverse events and line-related complications, and Quality of Life (QoL) scores at the start of micafungin course and 3 months later were extracted. Improvements in QoL were defined as an improvement of ≥4 points in at least one modality (symptom, impact, activity, total) in the St George's QoL score. A stable QoL score was defined as a change in score of <4 points in either direction whilst deterioration was defined as an increase of ≥4 points. RESULTS: There were 20 OPAT episodes involving 18 patients with a median duration of micafungin therapy of 21 (range: 4-248) days. Improvement or stability in the symptoms, activity, impact and total score was seen in 14 (78%), 12 (67%), 9 (50%) and 9 (50%) of the patients, respectively. However, half of the patients reported deterioration in the impact domain and total scores. By self-assessment, patients who categorised themselves as "poor" were comparable at the start of OPAT and at 3 months (43% vs 50%, McNemar's P = 0.7). Adverse events attributable to micafungin were recorded in 3 (14.3%) episodes. CONCLUSIONS: Micafungin may be safely administered via an OPAT service. Micafungin therapy was associated with an improvement or stability in QoL scores in at least 50% of the patients across the four domains.

The role of medical mycology societies in combating invasive fungal infections in low- and middle-income countries: A Nigerian model.

The discipline of medical mycology has become increasingly relevant in the face of the rising incidence of invasive fungal infections (IFI), which pose diagnostic and therapeutic challenges for contemporary medical practice. While firmly established in developed countries, medical mycology remains obscure in many low- and middle-income countries (LMICs). With a teeming vulnerable populace and an incidence rate of 11.8%, Nigeria has one of the highest estimated burdens of invasive fungal infections (IFIs) in the world. Regardless, the scourge of IFIs has remained silent due to a combination of factors principal amongst which are a lack of awareness and dearth in personnel skilled in diagnosis. The present narrative examines the status of medical mycology practice in Nigeria and chronicles the journey to change the status quo spurred by the Leading International Fungal Education (LIFE)-facilitated burden estimate paper and culminating in the birth of the Medical Mycology Society of Nigeria (MMSN), the pioneer national medical mycology society in Africa. The prospects of tackling the IFI challenge are highlighted from the perspective of the nascent society.

An account of the Ebola virus disease outbreak in Nigeria: implications and lessons learnt.

BACKGROUND: The 2014 Ebola virus disease (EVD) outbreak remains unprecedented both in the number of cases, deaths and geographic scope. The first case of EVD was confirmed in Lagos Nigeria on 23 July 2014 and spread to involve 19 laboratory-confirmed EVD cases. The EVD cases were not limited to Lagos State as Rivers State recorded 2 confirmed cases of EVD with 1 out of the 2 dying. Swift implementation of public health measures were sufficient to forestall a country -wide spread of this dreaded disease. This exploratory formative research describes the events of the Nigeria Ebola crisis in 2014. METHODS: This research was implemented through key informant in-depth interviews involving 15 stakeholders in the EVD outbreak in Nigeria by a team of two or three interviewers. Most of the interviews were conducted face-to-face at the various offices of the respondents and others were via the telephone. The interviews which lasted an hour on average were conducted in English, digitally recorded and notes were also taken. RESULTS: This study elucidated the public health response to the Ebola outbreak led by Lagos State Government in conjunction with the Federal Ministry of Health. The principal strategy was an incident management approach which saw them identify and successfully follow up 894 contacts. The infected EVD cases were quarantined and treated. The Nigerian private sector and international organizations made significant contributions to the control efforts. Public health enlightenment programmes using multimodal communication strategies were rapidly deployed. Water and sanitary facilities were provided in many public schools in Lagos. CONCLUSIONS: The 2014 Ebola outbreak in Nigeria was effectively controlled using the incident management approach with massive support provided by the private sector and international community. Eight of the confirmed cases of EVD in Nigeria eventually died (case fatality rate of 42.1%) and twelve were nursed back to good health. On October 20 2014 Nigeria was declared fee of EVD by the World Health Organization. The Nigerian EVD experience provides valuable insights to guide reforms of African health systems in preparation for future infectious diseases outbreaks.

Using a mHealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study.

BACKGROUND: The Ebola epidemic exposed the weak state of health systems in West Africa and their devastating effect on frontline health workers and the health of populations. Fortunately, recent reviews of mobile technology demonstrate that mHealth innovations can help alleviate some health system constraints such as balancing multiple priorities, lack of appropriate tools to provide services and collect data, and limited access to training in health fields such as mother and child health, HIV/AIDS and sexual and reproductive health. However, there is little empirical evidence of mHealth improving health system functions during the Ebola epidemic in West Africa. METHODS: We conducted quantitative cross-sectional surveys in 14 health facilities in Ondo State, Nigeria, to assess the effect of using a tablet computer tutorial application for changing the knowledge and attitude of health workers regarding Ebola virus disease. RESULTS: Of 203 participants who completed pre- and post-intervention surveys, 185 people (or 91%) were female, 94 participants (or 46.3%) were community health officers, 26 people (13 %) were nurses/midwives, 8 people (or 4%) were laboratory scientists and 75 people (37%) belonged to a group called others. Regarding knowledge of Ebola: 178 participants (or 87.7%) had foreknowledge of Ebola before the study. Further analysis showed an 11% improvement in average knowledge levels between pre- and post-intervention scores with statistically significant differences (P < 0.05) recorded for questions concerning the transmission of the Ebola virus among humans, common symptoms of Ebola fever and whether Ebola fever was preventable. Additionally, there was reinforcement of positive attitudes of avoiding the following: contact with Ebola patients, eating bush meat and risky burial practices as indicated by increases between pre- and post-intervention scores from 83 to 92%, 57 to 64% and 67 to 79%, respectively. Moreover, more participants (from 95 to 97%) reported a willingness to practice frequent hand washing and disinfecting surfaces and equipment following the intervention, and more health workers were willing (from 94 to 97%) to use personal protective equipment to prevent the transmission of Ebola. CONCLUSIONS: The modest improvements in knowledge and reported attitudinal change toward Ebola virus disease suggests mHealth tutorial applications could hold promise for training health workers and building resilient health systems to respond to epidemics in West Africa.

Implementing health worker training on sepsis in South Eastern Nigeria using innovative digital strategies: an interventional study.

Background: Sepsis is a leading cause of morbidity and mortality especially in low- and middle-income countries such as Nigeria. Training of health workers using digital platforms may improve knowledge and lead to better patient outcomes. Objectives: To assess the effectiveness of a digital health educational module on sepsis in improving the knowledge of medical doctors in Cross River State Nigeria on the diagnosis and management of patients presenting with sepsis. Design: Quasi-experimental analytical study. Methods: We developed and deployed a sepsis module through an innovative application (Sepsis tutorial app) to doctors in Calabar, Nigeria. We assessed quantitative pre- and post-intervention knowledge scores for those completing the tutorial on sepsis between both assessments. A user satisfaction survey evaluated the content of the tutorial and the usability of the app. Results: One hundred and two doctors completed the course. There were more males than females (58.8% versus 41.2%). Over half (52%) were junior doctors, a minority were general practitioners and house officers (3% and 5%, respectively), and 72.6% had practiced for periods ranging from 1 to 15 years post-qualification. Gender and age appeared to have no significant association with pre- and post-test scores. The oldest age group (61-70) had the lowest mean pre- and post-test scores, while general practitioners had higher mean pre- and post-test scores than other cadres. The majority (95%) of participants recorded higher post-test than pre-test scores with a significant overall increase in mean scores (25.5 ± 14.7%, p < 0.0001). Participants were satisfied with the content and multimodal delivery of the material and found the app usable. Conclusion: Digital training using context-responsive platforms is feasible and may be used to close the critical knowledge gap required to respond effectively to medical emergencies such as sepsis in low- to middle-income settings.

Training health workers on sepsis using digital strategies Sepsis occurs when the body injures itself as it attempts to fight an infection. It is now recognized as a leading cause of death especially in low- and middle-income countries such as Nigeria. Training of health workers using digital platforms may improve knowledge and lead to better patient outcomes. We assessed the effectiveness of a digital health educational course on sepsis in improving the knowledge of medical doctors in Cross River State, Nigeria on the diagnosis and management of patients presenting with sepsis. One hundred and two doctors completed the course. Most participants recorded higher post-test than pre-test scores, were generally satisfied with the content and delivery of the material, and found the app usable. We conclude that digital training using digital platforms may be useful in bridging the critical knowledge gap required to respond effectively to sepsis in low- to middle-income settings.

Advancing disease genomics beyond COVID-19 and reducing health disparities: what does the future hold for Africa?

The COVID-19 pandemic has ushered in high-throughput sequencing technology as an essential public health tool. Scaling up and operationalizing genomics in Africa is crucial as enhanced capacity for genome sequencing could address key health problems relevant to African populations. High-quality genomics research can be leveraged to improve diagnosis, understand the aetiology of unexplained illnesses, improve surveillance of infectious diseases and inform efficient control and therapeutic methods of known, rare and emerging infectious diseases. Achieving these within Africa requires strong commitment from stakeholders. A roadmap is needed to guide training of scientists, infrastructural development, research funding, international collaboration as well as promote public-private partnerships. Although the COVID-19 pandemic has significantly boosted genomics capacity in Africa, the continent still lags other regions. Here, we highlighted key initiatives in genomics research and efforts to address health challenges facing the diverse and fast-growing populations on the continent. We explore the scalability of genomic tools and techniques to tackle a broader range of infectious diseases in Africa, a continent that desperately requires a boost from genomic science.

Exploring the views of infection consultants in England on a novel delinked funding model for antimicrobials: the SMASH study.

Objectives: A novel 'subscription-type' funding model was launched in England in July 2022 for ceftazidime/avibactam and cefiderocol. We explored the views of infection consultants on important aspects of the delinked antimicrobial funding model. Methods: An online survey was sent to all infection consultants in NHS acute hospitals in England. Results: The response rate was 31.2% (235/753). Most consultants agreed the model is a welcome development (69.8%, 164/235), will improve treatment of drug-resistant infections (68.5%, 161/235) and will stimulate research and development of new antimicrobials (57.9%, 136/235). Consultants disagreed that the model would lead to reduced carbapenem use and reported increased use of cefiderocol post-implementation. The presence of an antimicrobial pharmacy team, requirement for preauthorization by infection specialists, antimicrobial stewardship ward rounds and education of infection specialists were considered the most effective antimicrobial stewardship interventions. Under the new model, 42.1% (99/235) of consultants would use these antimicrobials empirically, if risk factors for antimicrobial resistance were present (previous infection, colonization, treatment failure with carbapenems, ward outbreak, recent admission to a high-prevalence setting).Significantly higher insurance and diversity values were given to model antimicrobials compared with established treatments for carbapenem-resistant infections, while meropenem recorded the highest enablement value. Use of both 'subscription-type' model drugs for a wide range of infection sites was reported. Respondents prioritized ceftazidime/avibactam for infections by bacteria producing OXA-48 and KPC and cefiderocol for those producing MBLs and infections with Stenotrophomonas maltophilia, Acinetobacter spp. and Burkholderia cepacia. Conclusions: The 'subscription-type' model was viewed favourably by infection consultants in England.

Statin-use and perceptions of high cholesterol as predictors of healthy lifestyle behaviours in Nigerians.

It is unclear how statin-use influences the adoption of healthy lifestyle choices. It is important to understand the nature of this relationship as this could facilitate targeted public health interventions which could help promote a healthy lifestyle, curb the rise of non-communicable diseases, and facilitate overall health. This study aimed to explore whether statin-use influenced the adoption of healthy lifestyle choices by changing the way urban and semi-urban Nigerians thought about their high cholesterol and their future risk of cardiovascular disease. Structured questionnaires were used to compare the lifestyle behaviours, perceptions of high cholesterol and future risk of cardiovascular disease of statin users and non-statin users recruited in urban and a semi-urban Nigeria. In-depth, face-to-face interviews were used to further explore the relationship between statin-use and the adoption of healthy lifestyle choices, and explore the influence of personal and social factors on this relationship. The odds of adopting a low-fat diet increased as perceived statin-effectiveness increased (OR = 2.33, p<0.05), demonstrating a synergistic relationship between statin-use and the adoption of healthy of lifestyle choices. In addition to this synergistic association, at interview, two other relationships were found between statin use and the adoption of healthy lifestyle choices: an antagonistic relationship fuelled by a strong perception of statin effectiveness and a perceived inability to make healthy lifestyle changes, which favoured statin-use, and an antagonistic relationship fuelled by congruous cause-control beliefs and concerns about medication-use which favoured the adoption of healthy lifestyle choices. The odds of adopting a low-fat diet was 5 times greater in urban dwellers than in semi-urban dwellers (p<0.01). Statin-use influenced the adoption of healthy lifestyle choices in three different ways, which require exploration at clinical consultation. Gender, social obligations, and physical environment also influenced statin-use and the adoption of healthy lifestyle choices.

mHealth guideline training for non-communicable diseases in primary care facilities in Nigeria: a mixed methods pilot study.

OBJECTIVE: To pilot the use of a scalable innovative mobile health (mHealth) non-communicable diseases (NCDs) training application for nurses at the primary care level. DESIGN: Mixed methods pilot of mHealth training on NCD care for nurses at primary healthcare (PHC) facilities. We provide a descriptive analysis of mHealth training test scores, with trend analysis of blood pressure (BP) control using paired t-test for quantitative data and thematic analysis for qualitative data. SETTING: PHC facilities in rural and urban communities in Cross River State, south eastern Nigeria. NCDs were not part of routine training previously. As in most low-and-middle-income settings, funding for scale-up using conventional classroom in-service training for NCDs is not available in Nigeria, and onsite supervision poses challenges. PARTICIPANTS: Twenty-four health workers in 19 PHC facilities. INTERVENTION: A self-paced mHealth training module on an NCD desk guide was adapted to be applicable within the Nigerian context in collaboration with the Federal Ministry of Health. The training which focused on hypertension, diabetes and sickle cell disease was delivered via Android tablet devices, supplemented by quarterly onsite supervision and group support via WhatsApp. The training was evaluated with pre/post-course tests, structured observations and focus group discussions. This was an implementation pilot assessing the feasibility and potential effectiveness of mHealth training on NCD in primary care delivery. RESULTS: Nurses who received mHealth training recorded a statistically significant difference (p<0.001) in average pretest and post-test training scores of 65.2 (±12.2) and 86.5 (±7.9), respectively. Recordings on treatment cards indicated appropriate diagnosis and follow-up of patients with hypertension with significant improvements in systolic BP (t=5.09, p<0.001) and diastolic BP (t=5.07, p<0.001). The mHealth nurse training and WhatsApp support groups were perceived as valuable experiences and obviated the need for face-to-face training. Increased workload, non-availability of medications, facility-level conflicts and poor task shifting were identified challenges. CONCLUSIONS: This initiative provides evidence of the feasibility of implementing an NCD care package supported by mHealth training for health workers in PHCs and the strong possibility of successful scale-up nationally.