Predictors of Adequate Ambulatory Anticoagulation among Adult Patients in a Tertiary Teaching and Referral Hospital in Kenya

Background: Local anticoagulation services are inadequate and substantially underutilized despite compelling evidence showing that their appropriate use significantly reduces the risk of thromboembolic complications. Objectives: To determine the predictors of adequate ambulatory anticoagulation services in Kenyatta National Hospital. Methodology: A cross sectional study between December 2014 and April 2015 among 102 adult outpatients on anticoagulation using consecutive sampling was done. Information abstracted into a predesigned data collection tool included participants’ sociodemographic characteristics, regular sources of supply of anticoagulant, clinic pre-appointment reminders, indications of treatment and international normalized ratio tests. Data were analyzed using IBM Statistical Package for Social Sciences version 21.0 and logistic regression was used to determine independent predictors of adequate anticoagulation, which was defined as international normalized ratio ranging 2 - 3. Results: Females were majority (76.5 %) and only 27.5 % of patients  had adequate anticoagulation control. The indication of warfarin for heart valve surgery (p=0.014) and deep venous thrombosis (p=0.021) were associated with adequate anticoagulation. Age above 60 years was associated with poor anticoagulation (p=0.006). Logistic regression revealed that the independent predictor of adequate anticoagulation was warfarin use due to heart valve surgery (OR=3.1; 95% CI: 1.2 – 7.9, p=0.017). Conclusions: Ambulatory anticoagulation control in the hospital is poor. Further investigation is required to find out the reasons behind adequate anticoagulation in heart valve surgery patients. Key Words: Ambulatory anticoagulation, anticoagulant, outpatient, international normalized ratio tests

A comparative study in direct cryopreservative efficacy between Triladly® and EDTA saline glucose 10% glycerol cryopreservative media for human and non-human infective trypanosomes

application/pdfThe efficacy of Triladyl®, a commercial cryomedium for bull semen, in the cryopreservation of both human and animal infective trypanosomes as compared to EDTA Saline Glucose (ESG) 10% glycerol was evaluated in the current study. Cryopreserved Trypanosoma brucei rhodesiense, T. evansi, T. b. brucei and T. congolense were first propagated in irradiated mice. At the peak of parasitemia, parasites were harvested by cardiac puncture and 106,105,104103,102 and 10 dilutions made using whole blood bled from clean mice. These dilutions were divided into two equal portions of 0.5 ml each and cryopreserved in both ESG 10% glycerol and neat Triladly®. The procedure was also repeated with T. congolense and T. vivax species of trypanosomes directly isolated from naturally infected cattle. After 1 month of cryopreservation, 0.4 ml each portion of this dilution was injected intraperitonially into irradiated Swiss white mice. Results on pre-patent period (ppp) and progression of parasitemia showed no difference in the recovery of samples cryopreserved using the 2 media. However, mice injected with T. b. brucei cryopreserved in the 2 media showed highly significantly (p < 0.01 by t-test) lower ppp when compared to the other species of trypanosomes which had no significant difference. However, the ppp in mice injected with trypanosomes cryopreserved in ESG 10% glycerol was significantly lower (p < 0.05 by t-test) when compared to those cryopreserved in Triladyl®. The interaction between media and species was highly significant indicating therefore that the difference in cryopreservation between the two media varies from one species of trypanosome to the other. The interaction between dose and species was also highly significant (p < 0.01 by t-test) implying therefore that the effect of the inoculum dose varied from one species to the other leading to the conclusion therefore that although Triladyl® appears as good a cryopreservative medium as ESG 10% glycerol, the choice will be determined by the species of trypanosome.journal articl

Low-dose yellow fever vaccine in adults in Africa

BACKGROUND: Yellow fever vaccine is highly effective with a single dose, but vaccine supply is limited. The minimum dose requirements for seroconversion remain unknown. METHODS: In this double-blind, randomized, noninferiority trial in Uganda and Kenya, we assigned adults with no history of yellow fever vaccination or infection to receive vaccination with the Institut Pasteur de Dakar 17D-204 yellow fever vaccine at a standard dose (13,803 IU) or at a fractional dose of 1000 IU, 500 IU, or 250 IU. The primary outcome was seroconversion at 28 days after vaccination with each fractional dose as compared with the standard dose, evaluated in a noninferiority analysis. Seroconversion was defined as an antibody titer at day 28 that was at least four times as high as the antibody titer before vaccination, as measured by a plaque reduction neutralization test. We conducted noninferiority analyses in the per-protocol and intention-to-treat populations. Noninferiority was shown if the lower boundary of the 95% confidence interval for the difference in the incidence of seroconversion between the fractional dose and the standard dose was higher than −10 percentage points. RESULTS: A total of 480 participants underwent randomization (120 participants in each group). The incidence of seroconversion was 98% (95% confidence interval [CI], 94 to 100) with the standard dose. The difference in the incidence of seroconversion between the 1000-IU dose and the standard dose was 0.01 percentage points (95% CI, −5.0 to 5.1) in the intention-to-treat population and −1.9 percentage points (95% CI, −7.0 to 3.2) in the per-protocol population; the corresponding differences between the 500-IU dose and the standard dose were 0.01 percentage points (95% CI, −5.0 to 5.1) and −1.8 percentage points (95% CI, −6.7 to 3.2), and those between the 250-IU dose and the standard dose were −4.4 percentage points (95% CI, −9.4 to 0.7) and −6.7 percentage points (95% CI, −11.7 to 1.6). A total of 111 vaccine-related adverse events were reported: 103 were mild in severity, 7 were moderate, and 1 was severe. The incidence of adverse events was similar in the four groups. CONCLUSIONS: A yellow fever vaccination dose as low as 500 IU was noninferior to the standard dose of 13,803 IU for producing seroconversion within 28 days. (Funded by the European and Developing Countries Clinical Trials Partnership and the Wellcome Trust; NIFTY ClinicalTrials.gov number, NCT04059471.

Cost analysis of school-based intermittent screening and treatment of malaria in Kenya

<p>Abstract</p> <p>Background</p> <p>The control of malaria in schools is receiving increasing attention, but there remains currently no consensus as to the optimal intervention strategy. This paper analyses the costs of intermittent screening and treatment (IST) of malaria in schools, implemented as part of a cluster-randomized controlled trial on the Kenyan coast.</p> <p>Methods</p> <p>Financial and economic costs were estimated using an ingredients approach whereby all resources required in the delivery of IST are quantified and valued. Sensitivity analysis was conducted to investigate how programme variation affects costs and to identify potential cost savings in the future implementation of IST.</p> <p>Results</p> <p>The estimated financial cost of IST per child screened is US$6.61 (economic cost US$ 6.24). Key contributors to cost were salary costs (36%) and malaria rapid diagnostic tests (RDT) (22%). Almost half (47%) of the intervention cost comprises redeployment of existing resources including health worker time and use of hospital vehicles. Sensitivity analysis identified changes to intervention delivery that can reduce programme costs by 40%, including use of alternative RDTs and removal of supervised treatment. Cost-effectiveness is also likely to be highly sensitive to the proportion of children found to be RDT-positive.</p> <p>Conclusion</p> <p>In the current context, school-based IST is a relatively expensive malaria intervention, but reducing the complexity of delivery can result in considerable savings in the cost of intervention.</p> <p>(Costs are reported in US$ 2010).</p

Malaria Rapid Testing by Community Health Workers Is Effective and Safe for Targeting Malaria Treatment: Randomised Cross-Over Trial in Tanzania

Early diagnosis and prompt, effective treatment of uncomplicated malaria is critical to prevent severe disease, death and malaria transmission. We assessed the impact of rapid malaria diagnostic tests (RDTs) by community health workers (CHWs) on provision of artemisinin-based combination therapy (ACT) and health outcome in fever patients. Twenty-two CHWs from five villages in Kibaha District, a high-malaria transmission area in Coast Region, Tanzania, were trained to manage uncomplicated malaria using RDT aided diagnosis or clinical diagnosis (CD) only. Each CHW was randomly assigned to use either RDT or CD the first week and thereafter alternating weekly. Primary outcome was provision of ACT and main secondary outcomes were referral rates and health status by days 3 and 7. The CHWs enrolled 2930 fever patients during five months of whom 1988 (67.8%) presented within 24 hours of fever onset. ACT was provided to 775 of 1457 (53.2%) patients during RDT weeks and to 1422 of 1473 (96.5%) patients during CD weeks (Odds Ratio (OR) 0.039, 95% CI 0.029-0.053). The CHWs adhered to the RDT results in 1411 of 1457 (96.8%, 95% CI 95.8-97.6) patients. More patients were referred on inclusion day during RDT weeks (10.0%) compared to CD weeks (1.6%). Referral during days 1-7 and perceived non-recovery on days 3 and 7 were also more common after RDT aided diagnosis. However, no fatal or severe malaria occurred among 682 patients in the RDT group who were not treated with ACT, supporting the safety of withholding ACT to RDT negative patients. RDTs in the hands of CHWs may safely improve early and well-targeted ACT treatment in malaria patients at community level in Africa.\ud \ud \ud \u

Deployment of ACT antimalarials for treatment of malaria: challenges and opportunities

Following a long period when the effectiveness of existing mono-therapies for antimalarials was steadily declining with no clear alternative, most malaria-endemic countries in Africa and Asia have adopted artemisinin combination therapy (ACT) as antimalarial drug policy. Several ACT drugs exist and others are in the pipeline. If properly targeted, they have the potential to reduce mortality from malaria substantially. The major challenge now is to get the drugs to the right people. Current evidence suggests that most of those who need the drugs do not get them. Simultaneously, a high proportion of those who are given antimalarials do not in fact have malaria. Financial and other barriers mean that, in many settings, the majority of those with malaria, particularly the poorest, do not access formal healthcare, so the provision of free antimalarials via this route has only limited impact. The higher cost of ACT creates a market for fake drugs. Addressing these problems is now a priority. This review outlines current evidence, possible solutions and research priorities

Reviewing the literature on access to prompt and effective malaria treatment in Kenya: implications for meeting the Abuja targets

<p>Abstract</p> <p>Background</p> <p>Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment.</p> <p>In Kenya, the Division of Malaria Control is committed to ensuring that 80 percent of childhood fevers are treated with effective anti-malarial medicines within 24 hours of fever onset, but this target is largely unmet. This review aimed to document evidence on access to effective malaria treatment in Kenya, identify factors that influence access, and make recommendations on how to improve prompt access to effective malaria treatment. Since treatment-seeking patterns for malaria are similar in many settings in sub-Saharan Africa, the findings presented in this review have important lessons for other malaria endemic countries.</p> <p>Methods</p> <p>Internet searches were conducted in PUBMED (MEDLINE) and HINARI databases using specific search terms and strategies. Grey literature was obtained by soliciting reports from individual researchers working in the treatment-seeking field, from websites of major organizations involved in malaria control and from international reports.</p> <p>Results</p> <p>The review indicated that malaria treatment-seeking occurs mostly in the informal sector; that most fevers are treated, but treatment is often ineffective. Irrational drug use was identified as a problem in most studies, but determinants of this behaviour were not documented. Availability of non-recommended medicines over-the-counter and the presence of substandard anti-malarials in the market are well documented. Demand side determinants of access include perception of illness causes, severity and timing of treatment, perceptions of treatment efficacy, simplicity of regimens and ability to pay. Supply side determinants include distance to health facilities, availability of medicines, prescribing and dispensing practices and quality of medicines. Policy level factors are around the complexity and unclear messages regarding drug policy changes.</p> <p>Conclusion</p> <p>Kenya, like many other African countries, is still far from achieving the Abuja targets. The government, with support from donors, should invest adequately in mechanisms that promote access to effective treatment. Such approaches should focus on factors influencing multiple dimensions of access and will require the cooperation of all stakeholders working in malaria control.</p

The use of schools for malaria surveillance and programme evaluation in Africa.

Effective malaria control requires information on both the geographical distribution of malaria risk and the effectiveness of malaria interventions. The current standard for estimating malaria infection and impact indicators are household cluster surveys, but their complexity and expense preclude frequent and decentralized monitoring. This paper reviews the historical experience and current rationale for the use of schools and school children as a complementary, inexpensive framework for planning, monitoring and evaluating malaria control in Africa. Consideration is given to (i) the selection of schools; (ii) diagnosis of infection in schools; (iii) the representativeness of schools as a proxy of the communities they serve; and (iv) the increasing need to evaluate interventions delivered through schools. Finally, areas requiring further investigation are highlighted

School-based surveys of malaria in Oromia Regional State, Ethiopia: a rapid survey method for malaria in low transmission settings

BACKGROUND: In Ethiopia, malaria transmission is seasonal and unstable, with both Plasmodium falciparum and Plasmodium vivax endemic. Such spatial and temporal clustering of malaria only serves to underscore the importance of regularly collecting up-to-date malaria surveillance data to inform decision-making in malaria control. Cross-sectional school-based malaria surveys were conducted across Oromia Regional State to generate up-to-date data for planning malaria control interventions, as well as monitoring and evaluation of operational programme implementation. METHODS: Two hundred primary schools were randomly selected using a stratified and weighted sampling frame; 100 children aged five to 18 years were then randomly chosen within each school. Surveys were carried out in May 2009 and from October to December 2009, to coincide with the peak of malaria transmission in different parts of Oromia. Each child was tested for malaria by expert microscopy, their haemoglobin measured and a simple questionnaire completed. Satellite-derived environmental data were used to assess ecological correlates of Plasmodium infection; Bayesian geostatistical methods and Kulldorff's spatial scan statistic were employed to investigate spatial heterogeneity. RESULTS: A total 20,899 children from 197 schools provided blood samples, two selected schools were inaccessible and one school refused to participate. The overall prevalence of Plasmodium infection was found to be 0.56% (95% CI: 0.46-0.67%), with 53% of infections due to P. falciparum and 47% due to P. vivax. Of children surveyed, 17.6% (95% CI: 17.0-18.1%) were anaemic, while 46% reported sleeping under a mosquito net the previous night. Malaria was found at 30 (15%) schools to a maximum elevation of 2,187 metres, with school-level Plasmodium prevalence ranging between 0% and 14.5%. Although environmental variables were only weakly associated with P. falciparum and P. vivax infection, clusters of infection were identified within Oromia. CONCLUSION: These findings demonstrate the marked spatial heterogeneity of malaria in Oromia and, in general, Ethiopia, and provide a strong epidemiological basis for planning as well as monitoring and evaluating malaria control in a setting with seasonal and unstable malaria transmission