Can the initial success of the Malawi ART scale-up programme be sustained? The example of Queen Elizabeth Central Hospital, Blantyre

The antiretroviral therapy clinic of Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi was established as a fee-paying clinic in 2000. In 2004 a successful transition to free-of-charge antiretroviral therapy (ART) provision was made with the introduction of the national ART scale-up programme. Despite the human resource crisis in the healthcare system, remarkable improvements in quantity and quality of care, a reduction of defaulters, favourable ART outcomes and better access to ART for the poor, women and children were achieved. A number of challenges need to be overcome to sustain the initial success of the national ART scale-up programme in QECH, the most important being the shortage of ART staff in relation to the ever-expanding patient population.     

Introduction of voluntary counselling and rapid testing for HIV in rural South Africa: from theory to practice

Expanding access to voluntary counselling and testing (VCT) for HIV is an important first step in the development of a comprehensive package of HIV services. This article describes the introduction of VCT among five primary health care (PHC) facilities in a rural South African setting, alongside a multidimensional impact assessment as part of a national pilot programme. A baseline review of services demonstrated low levels of VCT, which were predominantly hospital-based. Twenty health workers in five PHC facilities were trained to provide VCT using rapid-testing assays. The feasibility of VCT introduction and its overall acceptability to clients and providers were evaluated using clinic testing registers, semi-structured interviews with counsellors and mock client encounters. One year after its introduction, a major increase in the quantity of HIV testing, the proportion of clients who receive their results, and the proportion who present voluntarily was observed. The majority of those presenting were women, and 20-40 year olds predominated. There was a high level of acceptance among health workers, and the quality of VCT was rated very good in mock client encounters. This work demonstrates one effective model for improving access to VCT through existing primary health care services in a rural South African context.     

我国血吸虫病防治项目管理与质量控制工作重点

本文围绕血吸虫病防治项目管理与质量控制工作, 总结了我国血防项目工作中的3种主要管理模式, 以及在国家法规、 国家规划、 国家标准和规范3个层面指导下的系统管理机制。通过灭螺工程的实例分析, 指出开展科学评估、 确保每项防治工作的质量是当前我国血防管理模式中值得探讨的问题之一。提出认真抓好血防项目管理的每个环节, 科学制定各项防治工作的操作规程, 规范防治专业人员工作流程, 是血防工作绩效考核的前提, 也是保证各项防治措施实施质量、发挥其应有防治效果的关键。     

Development and implementation of an HIV/AIDS case management outcomes assessment programme

The Case Management Section of the New York State Department of Health AIDS Institute coordinates the provision of case management services for people living with HIV/AIDS throughout the state. The Community Follow-Up Program (CFP), providing intensive case management for HIV-positive individuals and their families, operates under the auspices of the Case Management Section. This article focuses on a public/private outcomes assessment partnership, sponsored by the Case Management Section, and developed in conjunction with a team of CFP programme managers from across the state. The process used to develop outcome indicators and measures is described; challenges encountered along the way are detailed; and suggestions for other public/private partnerships are outlined. Results from two years of outcomes data collection are also presented. The article concludes that the inclusion of providers in the identification and measurement of desired outcomes can help overcome provider resistance to outcomes assessment and can help ensure that outcomes data are used to improve programme performance.     

The Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) collaborative quality improvement initiative in percutaneous coronary interventions

The past decade has been characterized by increased scrutiny of outcomes of surgical and percutaneous coronary interventions (PCIs). This increased scrutiny has led to the development of regional, state, and national databases for outcome assessment and for public reporting. This report describes the initial development of a regional, collaborative, cardiovascular consortium and the progress made so far by this collaborative group. In 1997, a group of hospitals in the state Michigan agreed to create a regional collaborative consortium for the development of a quality improvement program in interventional cardiology. The project included the creation of a comprehensive database of PCIs to be used for risk assessment, feedback on absolute and risk-adjusted outcomes, and sharing of information. To date, information from nearly 20,000 PCIs have been collected. A risk prediction tool for death in the hospital and additional risk prediction tools for other outcomes have been developed from the data collected, and are currently used by the participating centers for risk assessment and for quality improvement. As the project enters into year 5, the participating centers are deeply engaged in the quality improvement phase, and expansion to a total of 17 hospitals with active PCI programs is in process. In conclusion, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium is an example of a regional collaborative effort to assess and improve quality of care and outcomes that overcome the barriers of traditional market and academic competition.     

Efficacy of a limb-care regime in preventing acute adenolymphangitis in patients with lymphoedema caused by bancroftian filariasis, in Colombo, Sri Lanka

The efficacy of a programme of community home-based care (CHBC) for lymphoedematous limbs was evaluated among 163 lymphoedema patients attending two filariasis clinics in Colombo. Each patient was interviewed and examined and his or her lymphoedema was graded during a baseline assessment, before the CHBC programme, and again, during a post-intervention assessment, after the patient had been in the programme for 1 year. The number of patients having entry lesions was 24% lower at the post-intervention assessment than at the baseline (P<0.001), with a reduction in the frequency of each type of entry lesion investigated. In the year the patients were in the CHBC programme, 30% fewer of them experienced at least one attack of adenolymphangitis (ADL; P<0.001), the mean number of ADL attacks/patient was lower (P<0.001), and the mean duration of each ADL attack suffered was slightly shorter (5.70 v. 5.84 days; P>0.05) than in the year before the baseline assessment. The reduction in the incidence of ADL attacks was greatest in the patients with the higher grades of lymphoedema. Approximately 66% of the patients perceived an improvement in their swollen limb post-intervention. Eleven patients had grade-II lymphoedema at baseline but only grade-I lymphoedema after being on the CHBC programme for a year (P=0.012). The programme appeared to increase the frequencies with which patients followed each of the limb-care measures considered and most of the measures for the home management of ADL attacks that were investigated. It is recommended that the CHBC programme be implemented as a national programme in Sri Lanka.     

Knee replacement

Knee-replacement surgery is frequently done and highly successful. It relieves pain and improves knee function in people with advanced arthritis of the joint. The most common indication for the procedure is osteoarthritis. We review the epidemiology of and risk factors for knee replacement. Because replacement is increasingly considered for patients younger than 55 years, improved decision making about whether a patient should undergo the procedure is needed. We discuss assessment of surgery outcomes based on data for revision surgery from national joint-replacement registries and on patient-reported outcome measures. Widespread surveillance of existing implants is urgently needed alongside the carefully monitored introduction of new implant designs. Developments for the future are improved delivery of care and training for surgeons and clinical teams. In an increasingly ageing society, the demand for knee-replacement surgery will probably rise further, and we predict future trends. We also emphasise the need for new strategies to treat early-stage osteoarthritis, which will ultimately reduce the demand for joint-replacement surgery.     

迈向血吸虫病消除阶段的钉螺控制策略

钉螺是日本血吸虫的唯一中间宿主,钉螺控制是血吸虫病防治的重要措施之一。随着防治进程推进,我国血吸虫病呈低水平流行状态,但钉螺孳生和血吸虫病传播风险依然严峻。在新时期血吸虫病防治目标和环境保护等要求下,在钉螺控制中引入精准识别、精准干预和精准评价,巩固现有防治成效,将有助于推进我国消除血吸虫病进程。     

Implementation of the national programme for prevention of mother-to-child transmission of HIV: a rapid assessment in Cacadu district,South Africa

To conduct a rapid assessment of the prevention-of-mother-to-child-transmission-of-HIV (PMTCT) programme in two of the three local service areas in Cacadu district, Eastern Cape province, South Africa, we designed an exploratory study using a mixed-methods approach. Quantitative and qualitative data on PMTCT programme implementation were collected in 2008 through a structured assessment at the 44 health facilities implementing the programme in the province. This included in-depth interviews with 11 clinic supervisors, 31 clinic programme coordinators, and 8 hospital/maternity staff members in order to examine their perceived problems and suggestions regarding PMTCT programme implementation; an assessment of the clinic registers and recording systems; a meeting with stakeholders; and one feedback meeting with clinic managers, sub-district management and other stakeholders in regard to the results of the rapid assessment. Overall, most of the national criteria for PMTCT programme implementation were fulfilled across the health facilities. However, shortcomings were found relating to health policy, health services delivery and clients’ health-seeking behaviour. The findings show the need for a well-functioning health system with adequate and trained staff, a reduced staff workload, proper case recording, an improved patient follow-up system, better support for staff, the empowerment of PMTCT clients, strong leadership, and coordination and collaboration between partners.     

Outbreak of mumps associated with poor vaccine efficacy - Oporto Portugal 1996

Vaccination against mumps in Portugal began in 1987, with the introduction of the combined measles, mumps, and rubella vaccine (MMR) in the national vaccination programme (Programa Nacional de Vacinacao: PNV) for both sexes at 15 months. In November 1990,     

Burden of tuberculosis in an antiretroviral treatment programme in sub-Saharan Africa: impact on treatment outcomes and implications for tuberculosis control

OBJECTIVES: To determine burden and risk factors for tuberculosis (TB) in an antiretroviral treatment (ART) programme and its impact on ART outcomes. DESIGN: Prospective cohort study. METHODS: Prevalent TB was assessed at baseline and incident TB was ascertained prospectively over 3 years among 944 patients accessing a community-based ART programme in South Africa. RESULTS: At enrollment, median CD4 cell count was 96 cells/microl and 52% of patients had a previous history of TB. Prevalent TB (current antituberculosis treatment or active TB) was present in 25% and was strongly associated with advanced immunodeficiency. During 782 person-years of ART, 81 cases of TB were diagnosed. The incidence was 22.1/100 person-years during the first 3 months of ART and decreased to an average of 4.5/100 person-years during the second and third years. In multivariate analysis, risk of incident TB during follow-up was only associated with the current absolute CD4 cell count at that time point; an increase of 100 cells/mul was associated with a 25% lower risk (P = 0.007). Although prevalent and incident TB were associated with greater than two-fold increased mortality risk, they did not compromise immunological and virological outcomes among survivors at 48 weeks. CONCLUSIONS: Late initiation of ART was associated with a major burden of TB in this ART programme. TB reduced survival but did not impair immunovirological outcomes. Reductions in TB incidence during ART were dependent on CD4 cell count; however, after 3 years of treatment, rates were still 5- to 10-fold higher than among non-HIV-infected people. Earlier initiation of ART may reduce this burden of TB.     

Effectiveness of a balance training home exercise programme for adults with haemophilia: a pilot study

Summary.  Adults with haemophilia and other bleeding disorders often develop lower limb musculoskeletal problems associated with bleeds into joints and muscles, which may affect balance performance and increase likelihood of falling. The aim of this study was to evaluate the effectiveness of an individualized balance and strength home exercise programme on improving balance and related outcomes for adults with haemophilia and other bleeding disorders. Twenty male adults with haemophilia and other bleeding disorders (mean age 39.4 years, 95% CI = 33.7–45.1) were recruited to participate. They underwent a comprehensive clinical and force platform assessment of balance and related measures. Based on assessment findings, the assessing physiotherapist provided an individualized home exercise programme of balance, strengthening and walking exercises. Re-assessment occurred after the 4-month exercise programme. Twelve participants (60%) completed the programme and were re-assessed. There were no safety problems or dropouts associated with the exercise programme aggravating joint status. Although there were no statistically significant changes in any of the measures (adjusted for multiple comparisons), there were improvements of between 5% and 22% on 10 of the 16 measures, with the Neurocom modified Clinical Test of Sensory Interaction on Balance ( P  = 0.036) and Timed Sit to Stand ( P  = 0.064) approaching significance. A tailored home exercise programme targeting balance, strengthening and walking is feasible for adults with haemophilia and other bleeding disorders. These results suggest that positive physical outcomes including improved balance and mobility may be achieved with this type of programme.     

Rate of introduction of a low pathogenic avian influenza virus infection in different poultry production sectors in the Netherlands

Please cite this paper as: Gonzales et al. (2012) Rate of introduction of a low pathogenic avian influenza virus infection in different poultry production sectors in the Netherlands. Influenza and Other Respiratory Viruses DOI: 10.1111/j.1750‐2659.2012.00348.x. Background Targeted risk‐based surveillance of poultry types (PT) with different risks of introduction of low pathogenic avian influenza virus (LPAIv) infection may improve the sensitivity of surveillance. Objective To quantify the rate of introduction of LPAIv infections in different PT. Methods Data from the Dutch LPAIv surveillance programme (2007–2010) were analysed using a generalised linear mixed and spatial model. Results Outdoor‐layer, turkey, duck‐breeder and meat‐duck, farms had a 11, 8, 24 and 13 times higher rate of introduction of LPAIv than indoor‐layer farms, respectively. Conclusion Differences in the rate of introduction of LPAIv could be used to (re)design a targeted risk‐based surveillance programme.     

Management of community-acquired pneumonia by trained family general practitioners.

SETTING: Community-acquired pneumonia (CAP) is a respiratory health disease with a high prevalence in the general population. Family general practitioners (GPs) can play an important role in CAP management by reducing unnecessary hospital admissions and, consequently, national health costs. OBJECTIVE: To assess CAP management by trained GPs. DESIGN: A course in CAP management, including a risk classification method based only on clinical criteria, was developed within the framework of an educational programme. GPs who participated in the programme (n = 220) were asked to collect data on their CAP patients. RESULTS: GPs (n = 94, response rate 42.7%) provided information on 370 patients (50% males, aged 18-93 years). The numbers of patients judged to be at low, moderate and high risk were 81%, 13% and 6%, respectively. The admission rate was 19.5%. All home-treated patients had good clinical outcomes. Home treatment was based on quinolones (62%), beta-lactams (23%) and macrolides (15%). The attributable economic mean cost of antibiotic home treatment was euro 96 per episode (standard deviation 71, range 17-445). CONCLUSIONS: The good outcomes suggest that GPs managed their CAP patients well, adhering to the content of the CAP management course. The risk evaluation of patients admitted to hospital, based exclusively on clinical elements, was consistent with more complex classification.     

Perioperative outcomes and risk assessment in dialysis patients: current knowledge and future directions

Perioperative medicine is rapidly emerging as a key discipline to address the specific needs of high‐risk surgical groups, such as those on chronic dialysis. Crude hospital separation rates for chronic dialysis patients are considerably higher than patients with normal renal function, with up to 15% of admission being related to surgical intervention. Dialysis dependency carries substantial mortality and morbidity risk compared to patients with normal renal function. This group of patients has a high comorbid burden and complex medical need, making accurate perioperative planning essential. Existing perioperative risk assessment tools are unvalidated in chronic dialysis patients. Furthermore, they fail to incorporate important dialysis treatment‐related characteristics that could potentially influence perioperative outcomes. There is a dearth of information on perioperative outcomes of Australasian dialysis patients. Current perioperative outcome estimates stem predominantly from North American literature; however, the generalisability of these findings is limited, as the survival of North American dialysis patients is significantly inferior to their Australasian counterparts and potentially confounds reported perioperative outcomes; let alone regional variation in surgical indication and technique. We propose that data linkage between high‐quality national registries will provide more complete data with more detailed patient and procedural information to allow for more informative analyses to develop and validate dialysis‐specific risk assessment tools.     

Association of cervical SIL and HIV-1 infection among Zimbabwean women in an HIV/STI prevention study

A cross-sectional study was conducted on women attending family planning clinics in Harare, Zimbabwe to determine the prevalence of cervical neoplasia among HIV-1 positive women relative to an HIV-1 negative control group. Five hundred and fifty four women were recruited and the prevalence of HIV-1 was 36.8%. Cervical cytology was abnormal in 25.6% of HIV-infected women compared to only 6.7% HIV-1 seronegative women. Cervical neoplasia was significantly associated with HIV infection (chi(2)=42.4, P<0.001). Cellular changes typical of HPV infection (koilocytocis) were recorded in 6.4% of HIV infected women compared with 1.7% of HIV-1-uninfected women (chi(2)=8.43, P=0.004). HIV-1-positive women had twice the risk of having abnormal cervical cells than HIV-negative women (relative risk 2.47, odds ratio 10.14, P<0.001). Therefore the introduction of national cervical screening programme in HIV-1 endemic countries like Zimbabwe where the highest burden of pre-malignant lesions is among HIV-1-infected women needs careful planning because these women have other competing health needs including high rates of opportunistic infections.     

Assessing the impact of capacity building for HIV activists in Europe and Central Asia

ABSTRACT

STEP-UP is a capacity building and training programme for HIV community activists in Europe and Central Asia, led by the European AIDS Treatment Group (EATG). The programme aims to empower a new cohort of HIV activists each year to engage more deeply in HIV activism at local and national levels addressing key themes such as HIV treatment literacy, prevention technologies, living with HIV, project development, clinical trials, patient participation, advocacy and policy landscapes. The expected outcome of the project is that trainees become activists with knowledge of both policy and science who advocate for change to policy and or practice. To assess the impact of the programme on individual graduates, their organisations and the communities they work with, EATG conducted an evaluation of the programme for the period of 2013–2017. The methods used during the assessment were: a desk review of information about the programme; interviews with implementers and trainees; a focus group with trainees; inputs from national and regional networks, activists and references given by trainees; and an online survey of trainees. This article evaluates the lessons learnt and forms a set of recommendations to implement in the design of future editions of STEP-UP.     

Improved injection safety after targeted interventions in the Syrian Arab Republic

OBJECTIVES: Concerns about unsafe injection practices and possible infections with blood-borne pathogens in the Syrian Arab Republic motivated an assessment of the injection safety situation in the country in July 2001. In light of the recommendations from this assessment, the Ministry of Health of Syria, with the assistance of WHO, implemented a set of activities under the 'Focus Project', which aims to ensure immunization safety. The first phase of the project ran from May 2002 to February 2004, and consisted of the improved provision of injection safety equipment and supplies, the elaboration and wide distribution of national guidelines on injection safety and safe waste management, a behaviour change and communication campaign targeting the general public, and comprehensive training of healthcare workers. A follow-up survey was carried out in February 2004, 2 years after initiation of the project. METHODS: Two representative surveys were conducted using a standardized assessment tool. A cluster sampling strategy, with probability proportionate to the population size, led to the inclusion of 80 health facilities in eight districts in 2001 and of 120 health facilities in 12 districts in 2004. RESULTS: Injection practices had significantly improved 2 years after the start of the project. The 2001 study had pointed to a low, but non-negligible risk to patients (2% unsafe injections), coupled with a high risk to healthcare workers (61% reported needle-stick injuries in the last 12 months) and to the communities owing to unsafe waste disposal (sharps waste found outside 37% of health facilities, waste disposal considered unsafe in 48% of them). The 2004 survey showed that 90% of Syrian healthcare workers had received training in injection safety. All injections observed were given safely (difference to 2001 not significant), although some problems in preparation and reconstitution prevailed. The risk to healthcare workers was significantly reduced as only 14% of the staff reported needle-stick injuries (p < 0.001). The risk to the communities was notably decreased following improvements in sharps waste management (sharps were found in the surroundings of only 13% of health facilities, p < 0.001). CONCLUSIONS: The example of Syria shows that rapid improvement in injection safety is possible and that the necessary tools and methods to monitor and evaluate progress are at our disposal. Challenges remain in transferring this successful programme from the well-structured immunization programme to the more diverse curative health services.     

Participatory evaluations of trachoma control programmes in eight countries

Objectives Trachoma is a major cause of blindness. The objective of this initiative was to conduct participatory process evaluations of the trachoma control programmes receiving support from the International Trachoma Initiative in eight countries. Methods During each 2- to 4-week evaluation we analysed information collected at the central, district and community level through interviews, focus groups, questionnaires, direct observation of trachoma control activities, and existing data. Results Mapping and assessment of disease prevalence had been completed in four of eight countries. Integration of trachoma control activities into national planning and district-level service provision varied. Intersectoral partnerships to implement the SAFE strategy (i.e. surgery, antibiotics, facial cleanliness and environmental change) were well established in a few countries. In all eight countries, the number of surgeries performed annually was insufficient; and quality of surgery was rarely monitored. Mass distribution of antibiotics was carried out well in extremely resource-poor settings and good coverage was achieved, although the strategy for antibiotic distribution varied. Inadequate water and sanitation remained a major problem in all programme areas. Monitoring of programme activities was generally inadequate. The Morocco programme is an example from which lessons and processes can be learnt and adapted to other programme countries. Conclusions Significant achievements have been made in implementing the SAFE strategy. Scaling up of activities to true national coverage should be planned and implemented provided the resources can be made available. Further standardization of how to assess, implement and monitor trachoma control activities will facilitate expansion of the programme.