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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The yield and feasibility of integrated screening for TB, diabetes and HIV in four public hospitals in Ethiopia.

Background: Our objective was to demonstrate the feasibility of integrated care for TB, HIV and diabetes mellitus (DM) in a pilot project in Ethiopia. Methods: Healthcare workers in four hospitals screened patients with TB for HIV and DM; patients with HIV for DM and TB; and patients with DM for TB. Fasting and random plasma glucose (RPG) tests were used to confirm the diagnosis of DM. We used screening checklists for TB and DM, and additional risk scoring criteria to identify patients at risk of DM. Results: Of 3439 study participants, 888 were patients with DM, 439 patients with TB and 2112 from HIV clinics. Six of the patients with DM had TB of whom five were already on treatment; and 141 (32.4%) patients with TB had DM, of whom only five were previously diagnosed with DM. Symptomatic patients and those with a risk score of 5 or more were about three times more likely to have abnormal blood glucose level. Of 2075 HIV patients with RPG determined, only 31 (1.5%) had abnormal RPG. Conclusions: Tri-directional screening was feasible for detecting and managing previously undiagnosed TB and DM. More work is needed to better understand the interaction between HIV and DM.

High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized.

BACKGROUND: Maternal mortality due to abortion complications stands among the three leading causes of maternal death in Botswana where there is a restrictive abortion law. This study aimed at assessing the patterns and determinants of post-abortion complications. METHODS: A retrospective institution based cross-sectional study was conducted at four hospitals from January to August 2014. Data were extracted from patients' records with regards to their socio-demographic variables, abortion complications and length of hospital stay. Descriptive statistics and bivariate analysis were employed. RESULT: A total of 619 patients' records were reviewed with a mean (SD) age of 27.12 (5.97) years. The majority of abortions (95.5%) were reported to be spontaneous and 3.9% of the abortions were induced by the patient. Two thirds of the patients were admitted as their first visit to the hospitals and one third were referrals from other health facilities. Two thirds of the patients were admitted as a result of incomplete abortion followed by inevitable abortion (16.8%). Offensive vaginal discharge (17.9%), tender uterus (11.3%), septic shock (3.9%) and pelvic peritonitis (2.4%) were among the physical findings recorded on admission. Clinically detectable anaemia evidenced by pallor was found to be the leading major complication in 193 (31.2%) of the cases followed by hypovolemic and septic shock 65 (10.5%). There were a total of 9 abortion related deaths with a case fatality rate of 1.5%. Self-induced abortion and delayed uterine evacuation of more than six hours were found to have significant association with post-abortion complications (p-values of 0.018 and 0.035 respectively). CONCLUSION: Abortion related complications and deaths are high in our setting where abortion is illegal. Mechanisms need to be devised in the health facilities to evacuate the uterus in good time whenever it is indicated and to be equipped to handle the fatal complications. There is an indication for clinical audit on post-abortion care to insure implementation of standard protocol and reduce complications.

The experience of scaling up a decentralized, ambulatory model of care for management of multidrug-resistant tuberculosis in two regions of Ethiopia.

Strong strategies, including proven service delivery models, are needed to address the growing global threat of multidrug-resistant tuberculosis (MDR-TB) in low- and middle-income settings. The objective of this study was to assess the feasibility and effectiveness of the nationally approved ambulatory service delivery model for MDR-TB treatment in two regions of Ethiopia. We used routinely reported data to describe the process and outcomes of implementing an ambulatory model for MDR-TB services in a resource-limited setting. We compared percentage improvements in the number of MDR-TB diagnostic and treatment facilities, number of MDR-TB sputum samples processed per year, and MDR-TB cases ever enrolled in care between baseline and 2015. We also calculated interim and final treatment outcomes for patients who had completed at least 12 and 24 months of follow-up, respectively. Between 2012 and 2015, the number of MDR-TB treatment-initiating centers increased from 1 to 23. The number of sputum samples tested for MDR-TB increased 20-fold, from 662 to 14,361 per year. The backlog of patients on waiting lists was cleared. The cumulative number of MDR-TB patients put on treatment increased from 56 to 790, and the treatment success rate was 75%. Rapid expansion of the ambulatory model of MDR-TB care was feasible and achieved a high treatment success rate in two regions of Ethiopia. More effort is needed to sustain the gains and further decentralize services to the community level.

Factors influencing health care workers' implementation of tuberculosis contact tracing in Kweneng, Botswana.

INTRODUCTION: TB contact tracing rates remain low in high burden settings and reasons for this are not well known. We describe factors that influence health care workers' (HCW) implementation of TB contact tracing (CT) in a high TB burden district of Botswana. METHODS: Data were collected using questionnaires and in-depth interviews in 31 of the 52 health facilities in Kweneng East Health District. Responses were summarized using summary statistics and comparisons between HCW groups were done using parametric or non-parametric tests as per normality of the data distribution. RESULTS: One hundred and four HCWs completed questionnaires. Factors that influenced HCW TB contact tracing were their knowledge, attitudes and practices as well as personal factors including decreased motivation and lack of commitment. Patient factors included living further away from the clinic, unknown residential address and high rates of migration and mobility. Administrative factors included staff shortages, lack of transport, poor reporting of TB cases and poor medical infrastructure e.g. suboptimal laboratory services. A national HCW strike and a restructuring of the health system emerged as additional factors during in-depth interviews of TB coordinators. CONCLUSION: Multiple factors lead to poor TB contact tracing in this district. Interventions to increase TB contact tracing will be informed by these findings.