The (m)Health Connection: An Examination of the Promise of Mobile Phones for HIV/AIDS Intervention in Sub-Saharan Africa

This thesis offers an examination of the complex opportunities and challenges that characterize the development of innovative, locally appropriate, sustainable, and scalable uses of mobile phones as instruments to support and advance HIV/AIDS work in sub-Saharan Africa. Drawing together the fields of ICT4D and health communication, this thesis establishes a theoretical framework for mobile health (mHealth) interventions in developing countries from a critical media studies perspective. It interrogates the varied applications of mobile phones vis-à-vis health that have been identified, promoted, or piloted in sub-Saharan Africa and elsewhere in the Global South, focusing on the potential for mobile phones to enhance two interrelated aspects of HIV/AIDS work: 1) scaling-up prevention and awareness programs; and 2) enhancing access to treatment, care, and support for people living with HIV. By critically examining real-life applications, focusing in particular on a case study from South Africa (the pioneering mHealth organization Cell-Life), this thesis explores both the opportunities presented by the increasing ubiquity of mobile phones in this region, and the corresponding challenges, limitations, and critical issues that inhibit effective realization of mHealth’s potential in this context

Molecular epidemiology of antimicrobial resistance (AMR) and Shiga toxin producing E. coli (STEC) in dairy herds of central Zambia

Antimicrobial resistance (AMR) is a worldwide public health concern. While it is evident that the use of antibiotics creates selection pressure for the evolution of antibiotic resistance genes, there are still considerable knowledge gaps relating to the status quo of antibiotic use, emergence of resistant pathogens in different livestock production systems and spread within human and animal communities. This thesis includes a survey of antibiotic use in the dairy sector within a specific area of Zambia and analysis of AMR and virulence factors in E. coli isolated from dairy cattle and diarrhoea human patients with the following objectives. 1. To investigate the usage of antibiotics in the dairy sector and the drivers for use. 2. To determine the prevalence and patterns of antimicrobial resistance in E. coli isolated from faecal samples of dairy cattle. 3. To use whole genome sequencing (WGS) to investigate the molecular epidemiology of resistance determinants in E. coli strains isolated from both dairy cattle and humans. 4. To assess the zoonotic potential of isolated E. coli focusing on Shiga toxin-producing E. coli (STEC) and relationship to STEC associated with clinical disease in the UK. In view of these objectives, the first part of the work was carried out in Zambia and involved a questionnaire, a field survey, isolation of E. coli from dairy cattle faecal samples and phenotypic testing for AMR. In addition, E. coli isolates were obtained from another study that was focused on human patients presenting with diarrhoea at the University Teaching Hospital in Lusaka. The second part involved whole genome sequencing and molecular analyses of E. coli for resistance and virulence genotypes at the Roslin Institute (UK). For the field study, a stratified random sample of 104 farms was studied, representing approximately 20% of all dairy farms in the region. On each farm, faecal samples were collected from a random sample of animals and a standardised questionnaire on the usage of antibiotics was completed. An E. coli isolate was obtained from 98.67% (371/376) of the sampled animals and tested for resistance against the six types of antibiotics (tetracycline, ampicillin, sulfamethoxazole/trimethoprim, cefpodoxime, gentamicin and ciprofloxacin). These E. coli were then analysed together with those from humans for genotypes in the laboratory and from Illumina short read whole genome sequences using bioinformatics tools. Tetracylines and penicillin were the commonly used antibiotics in dairy herds. This finding was in line with the resistance phenotypes detected in E. coli isolated from the dairy cattle. The most prevalent AMR was to tetracycline (10.61; 95%CI: 7.40-13.82), followed by ampicillin (6.02; 95%CI: 3.31-8.73), sulfamethoxazole/ trimethoprim (4.49; 95%CI: 2.42-6.56), cefpodoxime (1.91; 95%CI: 0.46-3.36), gentamicin (0.89; 95%CI: 0.06-1.84) and ciprofloxacin (0%). The risk analysis indicated that AMR was associated with livestock diseases (lumpy skin disease and foot rot), exotic breeds (Jersey and Friesian), location, farm size and certain management practices. Analysis of whole genome sequences showed that isolates from humans had both higher levels and a greater diversity of resistance alleles than the cattle isolates. Common genotypes in both populations were: tetA (16%), tetB (10%), tetC (2%) for cattle isolates with tetA (32%), tetB (22%) and tetD (1%) in human isolates. Other common genotypes were blaTEM (56%), sul1 (29%), sul2 (66%), strA4 (57%) and strB1 (64%) in isolates of human origin while blaTEM (15%), sul1 (3%), sul2 (17%), strA4 (13%) and strB1 (19%) were in the cattle isolates. Whilst the E. coli isolates from cattle encoded resistance to common antibiotics of limited significance to human clinical medicine, isolates from humans had additional extended spectrum beta-lactamases (blaOXA, blaCMY, blaNDM, and blaDHA, blaOKP and blaCTX-M) that encode for resistance to essential antibiotics such as third generation cephalosporins and carbapenems. This was an evidence that AMR is an ongoing public health subject in Zambia but the exclusivity of certain resistances in the human population points to limited or no exchange of genotypes between E. coli of human origin and those from cattle. AMR in humans was probably independently selected by the use of antibiotics of clinical importance such as cephalosporin and fluoroquinolones. The virulence analysis focused on STEC, 11% (41/371) of E. coli isolates from cattle contained Shiga toxin genes (stx) while none (0/73) of the human isolates were positive. Phylogenetic analysis showed a random distribution of bovine STEC, with no indication of clonal spread. Although 89% (16/18) of the STEC tested had a cytotoxic effect on Vero cells, indicative of Shiga toxin production, only three (O45, O111, O157) belonged to one of the seven serogroups (O26, O157, O111, O103, O121, O145 and O45) associated with life-threatening enterohaemorrhagic E. coli (EHEC) infections in humans. In line with this, only the O157 serotype encoded a type 3 secretion system. This shows that, while Stx-encoding strains are common in these dairy herds of Zambia, they are not strain backgrounds known to pose an immediate threat to human health as they lack colonisation factors that are found in typical human EHEC. However, we must remain vigilant as emergence of EHEC strains in these animals remains an ever-present threat

Evaluation of Glibenclamide Quality and Stakeholders’ Perception of Medicine Quality in the Clinical Settings of the Ministry of Interior in Saudi Arabia

Aim: To explore medicine quality and perception among the stakeholders in the Ministry of Interior Medical Services (MOI-MSD) clinical settings in Saudi Arabia using glibenclamide as an indicator. Method: A mixed method approach was used in two phases. Phase one involved chemical analysis for identity and quantity of the active pharmaceutical ingredient (API), visual analysis and authentication of source of a popular diabetes medicine (glibenclamide) collected from MOI-MSD general warehouse in Riyadh, Saudi Arabia. Phase two contained a focus group discussion, self-completed survey questionnaires and semi-structured interviews to explore the perceptions of various stakeholders including commissioners, physicians, pharmacists and patients in the MOI-MSD settings in Saudi Arabia about medicine quality and related problems. Data analysis: Phase one collected quantitative data of API quantity from the chemical analysis of glibenclamide samples using a high performance liquid chromatography apparatus (HPLC) based on United States Pharmacopoeia (USP 36) method. The visual inspection of glibenclamide samples was performed using tool kit developed by The World Health Professions Alliance (WHPA) and The International Pharmaceutical Federation (FIP). The authentication of glibenclamide source was performed by on-site comparison of available samples in the general MOI-MSD warehouse with the available official reception documents. Phase two collected quantitative and qualitative data regarding perceptions about medicine quality and related problems and subsequently analysed them using SPSS for descriptive statistics and NVivo version 10 for thematic analysis following data coding and the development of themes and sub-themes. Subsequently, stakeholders’ data were triangulated to establish common and specific themes and sub-themes among MOI-MSD stakeholders. Findings: Phase one of the study found that all glibenclamide samples were within acceptable USP limits in terms of identity and quantity between 90-110%. It was also found that all available glibenclamide batch numbers were present in the official reception documents and the visual analysis of samples revealed no visible errors on the medicine samples or its packaging. Phase two of the study found that most stakeholders, particularly commissioners and physicians, believed that medicine quality was good or excellent in Saudi Arabia. However, the commissioners, physicians and pharmacists believed that the quality of medicines in the MOI-MSD was less than what is available in Saudi Arabia but patients mostly disagreed with these views. Most patients believed that the quality of medicines was high in both the Saudi Arabian market and in the MOI-MSD settings. Limited knowledge about good quality medicines and counterfeit medicines was found among most stakeholders where the quality of medicines was commonly associated with the effect rather than technical attributes of medicines including content, appearance and source. The stakeholders in this study reported a wide range of behaviour when in doubt about medicine quality such as reporting these doubts to authorities, finding alternative medicines, stopping the medicine use and taking no further action regarding these doubts. Furthermore, all stakeholders have identified medicine procurement focusing on price rather than quality, difficulty in reporting medicine quality problems and medicine storage conditions as challenges to medicine quality in the MOI-MSD. Patients, particularly chronic patients from Jeddah city, have complained about medicine non-availability in their local MOI-MSD primary clinic and expensive medicine prices. Conclusions: Glibenclamide quality in the MOI-MSD settings was found to be acceptable in terms of API identity and quantity, source and visual appearance. The perception about medicine quality in these settings seems to be low particularly from commissioners and pharmacists but not the patients. There is an urgent need to implement quality assurance steps to increase the commissioners and pharmacists trust in the quality of their medicines at the medicine selection, procurement, storage and transportation stages in addition to improving the accessibility to report medicine quality problems to all stakeholders. Subsequently, future research is needed to measure and evaluate the impact of these quality assurance steps on the confidence of commissioners and pharmacists trust in the quality of the MOI-MSD medicines. Furthermore, patients’ issues about medicine non-availability need to be addressed rapidly as it could result in patients’ acquiring medicines from unknown sources and/or cause additional financial burdens

Bowdoin Orient v.139, no.1-26 (2009-2010)

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