Research needs for an improved primary care response to chronic non‐communicable diseases in Africa

With non‐communicable diseases (NCDs) projected to become leading causes of morbidity and mortality in developing countries, research is needed to improve the primary care response, especially in sub‐Saharan Africa. This region has a particularly high double burden of communicable diseases and NCDs and the least resources for an effective response. There is a lack of good quality epidemiological data from diverse settings on chronic NCD burden in sub‐Saharan Africa, and the approach to primary care of people with chronic NCDs is currently often unstructured. The main primary care research needs are therefore firstly, epidemiological research to document the burden of chronic NCDs, and secondly, health system research to deliver the structured, programmatic, public health approach that has been proposed for the primary care of people with chronic NCDs. Documentation of the burden and trends of chronic NCDs and associated risk factors in different settings and different population groups is needed to enable health system planning for an improved primary care response. Key research issues in implementing the programmatic framework for an improved primary care response are how to (i) integrate screening and prevention within health delivery; (ii) validate the use of standard diagnostic protocols for NCD case‐finding among patients presenting to the local health facilities; (iii) improve the procurement and provision of standardised treatment and (iv) develop and implement a data collection system for standardised monitoring and evaluation of patient outcomes. Important research considerations include the following: selection of research sites and the particular NCDs targeted; research methodology; local research capacity; research collaborations; ethical issues; translating research findings into policy and practice and funding. Meeting the research needs for an improved health system response is crucial to deliver effective, affordable and equitable care for the millions of people with chronic NCDs in developing countries in Africa.     

Skin disorders among travellers returning from tropical and non‐tropical countries consulting a travel medicine clinic

Objective To evaluate the causes and risks for imported skin disorders among travellers. Methods Data of 34 162 travellers returning from tropical and non‐tropical countries and presenting at the outpatient travel medicine clinic of the University of Munich, Germany, between 1999 and 2009 were analyzed for this study. Of these, 12.2% were diagnosed with skin disorders. Results Main destinations visited were Asia (40%), Africa (27%) and Latin America (21%). Tourism in the form of adventure travel/backpacking (47%) and package holidays (23%) was the most common purpose of travel. The leading causes of skin disorders were arthropodal (23%), bacterial (22%), helminthic (11%), protozoan (6%), viral (6%), allergic (5%) and fungal (4%). The 10 most frequently diagnosed specific skin diseases associated with specific destinations were insect bites (17%, Southern Europe), cutaneous larva migrans (8%, Asia and Latin America), cutaneous leishmaniasis (2.4%, Mediterranean Region/Middle East), dengue fever (1.5%, Asia), rickettsioses (1.3%, Southern Africa), myiasis (0.8%, Central America), filarioses (0.7%, Africa), tick bites (0.6%, Central/Eastern Europe), schistosomiasis (0.6%, Africa) and tungiasis (0.6%, Africa). Travellers in sub‐Saharan Africa had the highest relative risk of acquiring skin disorders. Conclusion As more than 20% of all skin disorders among returned travellers were caused by arthropods and about 50% by infectious pathogens, pre‐travel consultations should include specific prophylaxis and consider the most important risk factor for the travel destination.     

Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub‐Saharan Africa: systematic review and meta‐analysis

Objectives To assess the proportion of patients lost to programme (died, lost to follow‐up, transferred out) between HIV diagnosis and start of antiretroviral therapy (ART) in sub‐Saharan Africa, and determine factors associated with loss to programme. Methods Systematic review and meta‐analysis. We searched PubMed and EMBASE databases for studies in adults. Outcomes were the percentage of patients dying before starting ART, the percentage lost to follow‐up, the percentage with a CD4 cell count, the distribution of first CD4 counts and the percentage of eligible patients starting ART. Data were combined using random‐effects meta‐analysis. Results Twenty‐nine studies from sub‐Saharan Africa including 148 912 patients were analysed. Six studies covered the whole period from HIV diagnosis to ART start. Meta‐analysis of these studies showed that of the 100 patients with a positive HIV test, 72 (95% CI 60–84) had a CD4 cell count measured, 40 (95% CI 26–55) were eligible for ART and 25 (95% CI 13–37) started ART. There was substantial heterogeneity between studies (P < 0.0001). Median CD4 cell count at presentation ranged from 154 to 274 cells/μl. Patients eligible for ART were less likely to become lost to programme (25%vs. 54%, P < 0.0001), but eligible patients were more likely to die (11%vs. 5%, P < 0.0001) than ineligible patients. Loss to programme was higher in men, in patients with low CD4 cell counts and low socio‐economic status and in recent time periods. Conclusions Monitoring and care in the pre‐ART time period need improvement, with greater emphasis on patients not yet eligible for ART.     

Do self‐assessments of health predict future mortality in rural South Africa? The case of KwaZulu‐Natal in the era of antiretroviral treatment

Objectives While self‐assessments of health (SAH) are widely employed in epidemiological studies, most of the evidence on the power of SAH to predict future mortality originates in the developed world. With the HIV pandemic affecting largely prime age individuals, the strong association between SAH and mortality derived from previous work might not be relevant for the younger at‐risk groups in countries with high HIV prevalence in the era of antiretroviral treatment. We investigate the power of SAH to predict mortality in a community with high HIV prevalence and antiretroviral treatment (ART) coverage using linked data from three sources: a longitudinal demographic surveillance, one of Africa’s largest, longitudinal, population‐based HIV surveillances, and a decentralised rural HIV treatment and care programme. Methods We used a Cox proportional hazards specification to examine whether SAH significantly predicts mortality hazard in a sample composed of 9217 adults aged 15–54, who were followed up for mortality for 8 years. Results Self‐assessments of health strongly predicted mortality (within 4 years of follow‐up), with a clear gradient of the adjusted hazard ratios (aHRs), relative to the baseline of ‘excellent’ self‐assessed health status and controlling for age, gender, marital status, the socio‐economic status (SES), variables education, employment, household expenditures and household assets, and HIV status and ART uptake: 1.40 (95% CI 0.99–1.96) for ‘very good’ self‐assessed health status (SAHS); 2.10 (95% CI 1.52–2.90) for ‘good’ SAHS; 3.12 (95% CI 2.18–4.45) for ‘fair’ SAHS; and 4.64 (95% CI 2.93–7.35) for ‘poor’ SAHS. While a similar association remained in the unadjusted analysis of long‐term mortality (within 4–8 years of follow‐up) the hazard ratios capturing SAH are jointly insignificant in predicting of mortality once HIV status, ART uptake and gender, age, marital status and SES were controlled for. HIV status and ART programme participation were large and highly significant predictors of long‐term mortality. Conclusions Our findings validate SAH as a variable that significantly predicts short‐term mortality in a community in sub‐Saharan Africa with high HIV prevalence, morbidity and mortality. When predicting long‐term mortality, however, it is much more important to know a person's HIV status and ART programme participation than SAH.     

Non‐physician cataract surgeons in Sub‐Saharan Africa: situation analysis

Objectives Non‐physician cataract surgeons (NPCS) provide cataract surgical services in some Sub‐Saharan African (SSA) countries. However, their training, placement, legal framework and supervision have not been documented. We sought to do so to inform decision‐making regarding future training. Methods Standard questionnaires were sent to national eye coordinators and other ophthalmologic leaders in Africa to collect information. Face‐to‐face interviews were conducted at training programmes in Ethiopia, Tanzania and Kenya, and email interviews were conducted with directors at training programmes in the Gambia and Malawi. Results Responses were provided for 31/39 (79%) countries to which questionnaires were sent. These countries represent about 90% of the population of SSA. Overall, 17 countries have one or more NPCS; two‐thirds of the total 245 NPCS are found in only three countries. Thirty‐six percent of NPCS work alone, but a formal functioning supervision system was reported to be present in only one country. The training centres are similar and face similar challenges. Conclusions There is considerable variation across SSA in the use and acceptance of NPCS. The placement and support of NPCS after training generally does not follow expectations, and training centres have little role in this. Overall, there was no consensus on whether the cadre, as it is currently viewed, is necessary, desirable or will contribute to addressing cataract surgical needs in SSA.     

Prices of antihypertensive medicines in sub‐Saharan Africa and alignment to WHO’s model list of essential medicines

Objective To investigate compliance of National Essential Medicines Lists (NEMLs) with the WHO Essential Medicines List (WHO/EML) in 2007 and to compare prices of antihypertensive drugs in and between 13 sub‐Saharan African countries. Methodology Data on NEMLs and drug prices were collected from 65 public and 65 private pharmacies (five of each per country). Prices were compared with the International Drug Price Indicator Guide (IDPIG). The cost of drug treatment within a country was calculated using defined daily doses (DDD) and between countries using DDD prices adjusted for purchasing power parity‐based gross domestic product per capita. Results All surveyed countries had a NEML. However, none of these lists were in complete alignment with the 2007 WHO/EML, and 38% had not been updated in the last 5 years. Surveyed medicines were cheaper when on the NEMLs; they were also cheaper in public than in private pharmacies. Prices varied greatly per medicine. A large majority of the public prices were higher than those indicated by the IDPIG. Overall, hydrochlorothiazide is the cheapest drug. Conclusion There are substantial differences in NEML composition between the 13 countries. The proportion of NEMLs not regularly updated was double the global United Nations estimates. Prices of WHO/EML‐advised drugs differ greatly between drugs and for each drug within and between countries. In general, the use of drugs on the NEML improves financial accessibility, and these drugs should be prescribed preferentially.     

Heart failure in sub‐Saharan Africa: review of the aetiology of heart failure and the role of point‐of‐care biomarker diagnostics

Within Africa, the burden of heart failure is significant. This arises from the increase in cardiovascular disease and associated risk factors such as hypertension and diabetes, as well as causes of heart failure which are particular to sub‐Saharan Africa, such as endomyocardial fibrosis. The lack of access to echocardiography and other imaging modalities, from a cost and technical perspective, combined with the predominantly rural nature of many countries with poor transport links, means that the vast majority of people never obtain an appropriate diagnosis. Similarly, research has been limited on the causes and treatment of heart failure in Africa and in particular endemic causes such as EMF and rheumatic heart disease. This review outlines the burden of heart failure in Africa and highlights the opportunity to expand diagnosis through the use of biomarkers, in particular natriuretic peptides. This builds on the success of point‐of‐care testing in human immunodeficiency virus and tuberculosis which have been extensively deployed in community settings in Africa.     

Participation in medical research as a resource‐seeking strategy in socio‐economically vulnerable communities: call for research and action

The freedom to consent to participate in medical research is a complex subject, particularly in socio‐economically vulnerable communities, where numerous factors may limit the efficacy of the informed consent process. Informal consultation among members of the Switching the Poles Clinical Research Network coming from various sub‐Saharan African countries, that is Burkina Faso, The Gambia, Rwanda, Ethiopia, the Democratic Republic of Congo (DRC) and Benin, seems to support the hypothesis that in socio‐economical vulnerable communities with inadequate access to health care, the decision to participate in research is often taken irrespectively of the contents of the informed consent interview, and it is largely driven by the opportunity to access free or better quality care and other indirect benefits. Populations' vulnerability due to poverty and/or social exclusion should obviously not lead to exclusion from medical research, which is most often crucially needed to address their health problems. Nonetheless, to reduce the possibility of exploitation, there is the need to further investigate the complex links between socio‐economical vulnerability, access to health care and individual freedom to decide on participation in medical research. This needs bringing together clinical researchers, social scientists and bioethicists in transdisciplinary collaborative research efforts that require the collective input from researchers, research sponsors and funders.     

Moving from vertical to integrated child health programmes: experiences from a multi‐country assessment of the Child Health Days approach in Africa

Objectives To assess the effect of child health days (CHDs) on coverage of child survival interventions, to document country experiences with CHDs and to identify ways in which CHDs have strengthened or depleted primary health care (PHC) services. Methods Programme evaluation in six countries in sub‐Saharan Africa using both quantitative (review of routine child health indicators) and qualitative (key informant interviews) methods. Results We found that CHDs have raised the profile of child survival at different levels from central government to the community in all six countries. The approach has increased the coverage of vitamin A supplementation and immunizations, especially in previously poorly performing countries. However, similar improvements have not occurred in non‐CHD interventions, most notably exclusive breastfeeding. There were examples of duplication, especially in the capturing and use of health information. There was widespread evidence that PHC staff were being diverted from their usual PHC functions, and managers reported being distracted by the time required for the planning and execution of CHDs. Finally, there were examples of where the routine PHC system is becoming distorted through, for example, the payment of health worker incentives during CHD activities only. Conclusion Interventions such as CHDs can rapidly increase coverage of key child survival interventions; however, they need to do so in a manner that strengthens rather than depletes existing PHC services. Our findings suggest that stand alone child health day interventions may gradually need to be integrated with routine PHC through more general health system strengthening.     

Non‐typhoidal Salmonella rates in febrile children at sites in five Asian countries

There is increased recognition of non‐typhoidal Salmonella (NTS) as a major cause of severe febrile illness in sub‐Saharan Africa. However, little is known about community‐based incidence of NTS in Asia. In a multicentre, community‐based prospective Salmonella surveillance study, we identified a total of six NTS cases: three in Karachi, Pakistan, one in Kolkata, India, and two in North Jakarta, Indonesia. No NTS cases were identified in Hechi, People’s Republic of China, and Hue, Viet Nam. Three cases were in children under 3 years, and one case was in a child aged 10 years and one in a child aged 15 years. Only one case was an adult (29 years). The highest incidence of NTS infection was in Karachi (7.2 culture‐proven NTS cases per 100 000 person years in age group of 2–15 years). However, in comparison with sub‐Saharan Africa, the NTS burden in Asia appears rather limited.     

Mortality measurement in transition: proof of principle for standardised multi‐country comparisons

Objective To demonstrate the viability and value of comparing cause‐specific mortality across four socioeconomically and culturally diverse settings using a completely standardised approach to VA interpretation. Methods Deaths occurring between 1999 and 2004 in Butajira (Ethiopia), Agincourt (South Africa), FilaBavi (Vietnam) and Purworejo (Indonesia) health and socio‐demographic surveillance sites were identified. VA interviews were successfully conducted with the caregivers of the deceased to elicit information on signs and symptoms preceding death. The information gathered was interpreted using the InterVA method to derive population cause‐specific mortality fractions for each of the four settings. Results The mortality profiles derived from 4784 deaths using InterVA illustrate the potential of the method to characterise sub‐national profiles well. The derived mortality patterns illustrate four populations with plausible, markedly different disease profiles, apparently at different stages of health transition. Conclusions Given the standardised method of VA interpretation, the observed differences in mortality cannot be because of local differences in assigning cause of death. Standardised, fit‐for‐purpose methods are needed to measure population health and changes in mortality patterns so that appropriate health policy and programmes can be designed, implemented and evaluated over time and place. The InterVA approach overcomes several longstanding limitations of existing methods and represents a valuable tool for health planners and researchers in resource‐poor settings.     

Linking women who test HIV‐positive in pregnancy‐related services to long‐term HIV care and treatment services: a systematic review

Objectives To quantify attrition between women testing HIV‐positive in pregnancy‐related services and accessing long‐term HIV care and treatment services in low‐ or middle‐income countries and to explore the reasons underlying client drop‐out by synthesising current literature on this topic. Methods A systematic search in Medline, EMBASE, Global Health and the International Bibliography of the Social Sciences of literature published 2000–2010. Only studies meeting pre‐defined quality criteria were included. Results Of 2543 articles retrieved, 20 met the inclusion criteria. Sixteen (80%) drew on data from sub‐Saharan Africa. The pathway between testing HIV‐positive in pregnancy‐related services and accessing long‐term HIV‐related services is complex, and attrition was usually high. There was a failure to initiate highly active antiretroviral therapy (HAART) among 38–88% of known‐eligible women. Providing ‘family‐focused care’, and integrating CD4 testing and HAART provision into prevention of mother‐to‐child HIV transmission services appear promising for increasing women’s uptake of HIV‐related services. Individual‐level factors that need to be addressed include financial constraints and fear of stigma. Conclusions Too few women negotiate the many steps between testing HIV‐positive in pregnancy‐related services and accessing HIV‐related services for themselves. Recent efforts to stem patient drop‐out, such as the MTCT‐Plus Initiative, hold promise. Addressing barriers and enabling factors both within health facilities and at the levels of the individual woman, her family and society will be essential to improve the uptake of services.     

Advances with vaccination against Neisseria meningitidis

In the last decade, meningococcal serogroup C conjugate vaccination programs have been demonstrated to be hugely successful with a truly impressive public health impact. In sub‐Saharan Africa, with the implementation of an affordable serogroup A conjugate vaccine, it is hoped that a similar public health impact will be demonstrated. Challenges still remain in the quest to develop and implement broadly protective vaccines against serogroup B disease. New, broad coverage vaccines against serogroup B are for the first time becoming available although little is known about their antibody persistence, effectiveness or effect on nasopharyngeal carriage. Enhanced surveillance following any potential vaccine introduction against serogroup B needs to be thoroughly implemented. The future now holds a distinct possibility, globally, for substantially decreasing meningococcal disease, regardless of infecting serogroup.     

First attempt to validate the gSG6‐P1 salivary peptide as an immuno‐epidemiological tool for evaluating human exposure to Anopheles funestus bites

Objective The development of a biomarker of exposure based on the evaluation of the human antibody response specific to Anopheles salivary proteins seems promising in improving malaria control. The IgG response specific to the gSG6‐P1 peptide has already been validated as a biomarker of An. gambiae exposure. This study represents a first attempt to validate the gSG6‐P1 peptide as an epidemiological tool evaluating exposure to An. funestus bites, the second main malaria vector in sub‐Saharan Africa. Methods A multi‐disciplinary survey was performed in a Senegalese village where An. funestus represents the principal anopheline species. The IgG antibody level specific to gSG6‐P1 was evaluated and compared in the same children before, at the peak and after the rainy season. Results Two‐thirds of the children developed a specific IgG response to gSG6‐P1 during the study period and – more interestingly – before the rainy season, when An. funestus was the only anopheline species reported. The specific IgG response increased during the An. funestus exposure season, and a positive association between the IgG level and the level of exposure to An. funestus bites was observed. Conclusions The results suggest that the evaluation of the IgG response specific to gSG6‐P1 in children could also represent a biomarker of exposure to An. funestus bites. The availability of such a biomarker evaluating the exposure to both main Plasmodium falciparum vectors in Africa could be particularly relevant as a direct criterion for the evaluation of the efficacy of vector control strategies.     

What is new in HIV/AIDS research in developing countries?

HIV epidemic has had greatest impact in sub‐Saharan Africa (SSA) and mainly in East and Southern Africa with HIV prevalence in some parts going up to 30%. In the recent years, considerable HIV research on prevention, treatment and care, and vaccine has been conducted in many developing countries and provided evidence‐based knowledge to control the epidemic. However, there have also been disappointing results in HIV prevention trials such as in HIV vaccine and microbicide trials. Despite these outcomes, important lessons have been learnt that help in designing future trials. This article examines the recent advances in HIV research in developing countries. The most recent HIV prevention research has demonstrated the effect of male circumcision on HIV acquisition, and lack of impact of HSV‐2 treatment on HIV transmission and acquisition. Use of HIV antiretroviral drugs (ARVs) for HIV prevention is a new area that has attracted interest and a number of trials are examining the effect of oral Pre‐Exposure Prophylaxis on HIV acquisition and also looking at the potential of ARVs in reducing infectiousness. Progress has been made in HIV treatment, monitoring treatment efficacy and toxicity as well as evaluation of different models of ART delivery. HIV vaccine research has, however, faced most challenges despite many efforts that have been put in. Looking into the future, there are ongoing trials that will hopefully generate important information to strengthen HIV policies in the next few years. There are, however, many other gaps in HIV research that need to be urgently addressed.     

Epidemiology and control of trachoma: systematic review

Trachoma is the commonest infectious cause of blindness. Recurrent episodes of infection with serovars A–C of Chlamydia trachomatis cause conjunctival inflammation in children who go on to develop scarring and blindness as adults. It was estimated that in 2002 at least 1.3 million people were blind from trachoma, and currently 40 million people are thought to have active disease and 8.2 million to have trichiasis. The disease is largely found in poor, rural communities in developing countries, particularly in sub‐Saharan Africa. The WHO promotes trachoma control through a multifaceted approach involving surgery, mass antibiotic distribution, encouraging facial cleanliness and environmental improvements. This has been associated with significant reductions in the prevalence of active disease over the past 20 years, but there remain a large number of people with trichiasis who are at risk of blindness.     

Review of multidrug‐resistant and extensively drug‐resistant TB: global perspectives with a focus on sub‐Saharan Africa

Tuberculosis (TB) remains a global emergency and is responsible for 1.7 million deaths annually. Widespread global misuse of isoniazid and rifampicin over three decades has resulted in emergence of the ominous spread of multidrug‐resistant TB (MDR‐TB) and extensively drug‐resistant TB (XDR‐TB) globally. These difficult to treat resistant forms of TB are increasingly seen in Asia, Eastern Europe, South America and sub‐Saharan Africa, disrupting TB and HIV control programmes. We review the latest available global epidemiological and clinical evidence on drug‐resistant TB in HIV‐infected and uninfected populations, with focus on Africa where data are scanty because of poor diagnostic and reporting facilities. The difficult management and infection control problems posed by drug‐resistant TB in HIV‐infected patients are discussed. Given the increasing current global trends in MDR‐TB, aggressive preventive and management strategies are urgently required to avoid disruption of global TB control efforts. The data suggest that existing interventions, public health systems and TB and HIV programmes must be strengthened significantly. Political and funder commitment is essential to curb the spread of drug‐resistant TB.     

How to improve the validity of sexual behaviour reporting: systematic review of questionnaire delivery modes in developing countries

Objectives To systematically review comparative research from developing countries on the effects of questionnaire delivery mode. Methods We searched Medline, EMbase and PsychINFO and ISSTDR conference proceedings. Randomized control trials and quasi‐experimental studies were included if they compared two or more questionnaire delivery modes, were conducted in a developing country, reported on sexual behaviours and occurred after 1980. Results A total of 28 articles reporting on 26 studies met the inclusion criteria. Heterogeneity of reported trial outcomes between studies made it inappropriate to combine trial outcomes. Eighteen studies compared audio computer‐assisted survey instruments (ACASI) or its derivatives [personal digital assistant (PDA) or computer‐assisted personal interview (CAPI)] against another self‐administered questionnaires, face‐to‐face interviews or random response technique. Despite wide variation in geography and populations sampled, there was strong evidence that computer‐assisted interviews lowered item‐response rates and raised rates of reporting sensitive behaviours. ACASI also improved data entry quality. A wide range of sexual behaviours were reported including vaginal, oral, anal and/or forced sex, age of sexual debut, condom use at first and/or last sex. Validation of self‐reports using biomarkers was rare. Conclusions These data reaffirm that questionnaire delivery modes do affect self‐reported sexual behaviours and that use of ACASI can significantly reduce reporting bias. Its acceptability and feasibility in developing country settings should encourage researchers to consider its use when conducting sexual health research. Triangulation of self‐reported data using biomarkers is recommended. Standardizing sexual behaviour measures would allow for meta‐analysis.     

Lymphomas in sub‐Saharan Africa – what can we learn and how can we help in improving diagnosis,managing patients and fostering translational research?

Approximately 30 000 cases of non‐Hodgkin lymphoma (NHL) occur in the equatorial belt of Africa each year. Apart from the fact that Burkitt lymphoma (BL) is very common among children and adolescents in Africa and that an epidemic of human immunodeficiency virus (HIV) infection is currently ongoing in this part of the world, very little is known about lymphomas in Africa. This review provides information regarding the current infrastructure for diagnostics in sub‐Saharan Africa. The results on the diagnostic accuracy and on the distribution of different lymphoma subsets in sub‐Saharan Africa were based on a review undertaken by a team of lymphoma experts on 159 fine needle aspirate samples and 467 histological samples during their visit to selected sub‐Saharan African centres is presented. Among children (<18 years of age), BL accounted for 82% of all NHL, and among adults, diffuse large B‐cell lymphoma accounted for 55% of all NHLs. Among adults, various lymphomas other than BL, including T‐cell lymphomas, were encountered. The review also discusses the current strategies of the International Network of Cancer Treatment and Research on improving the diagnostic standards and management of lymphoma patients and in acquiring reliable clinical and pathology data in sub‐Saharan Africa for fostering high‐quality translational research.