Building Research Capacity in Africa: Equity and Global Health Collaborations

Kathryn Chu and colleagues discuss the impact of high-income country investigators conducting research in low- and middle-income countries and explore lessons from the effective and equitable relationships that exist. Please see later in the article for the Editors' Summar

Giving tranexamic acid to reduce surgical bleeding in sub-Saharan Africa: an economic evaluation

BACKGROUND: The identification of safe and effective alternatives to blood transfusion is a public health priority. In sub-Saharan Africa, blood shortage is a cause of mortality and morbidity. Blood transfusion can also transmit viral infections. Giving tranexamic acid (TXA) to bleeding surgical patients has been shown to reduce both the number of blood transfusions and the volume of blood transfused. The objective of this study is to investigate whether routinely administering TXA to bleeding elective surgical patients is cost effective by both averting deaths occurring from the shortage of blood, and by preventing infections from blood transfusions. METHODS: A decision tree was constructed to evaluate the cost-effectiveness of providing TXA compared with no TXA in patients with surgical bleeding in four African countries with different human immunodeficiency virus (HIV) prevalence and blood donation rates (Kenya, South Africa, Tanzania and Botswana). The principal outcome measures were cost per life saved and cost per infection averted (HIV, Hepatitis B, Hepatitis C) averted in 2007 International dollars ($). The probability of receiving a blood transfusion with and without TXA and the risk of blood borne viral infection were estimated. The impact of uncertainty in model parameters was explored using one-way deterministic sensitivity analyses. Probabilistic sensitivity analysis was performed using Monte Carlo simulation. RESULTS: The incremental cost per life saved is$87 for Kenya and $93 for Tanzania. In Botswana and South Africa, TXA administration is not life saving but is highly cost saving since fewer units of blood are transfused. Further, in Botswana the administration of TXA averts one case of HIV and four cases of Hepatitis B (HBV) per 1,000 surgical patients. In South Africa, one case of HBV is averted per 1,000 surgical patients. Probabilistic sensitivity analyses confirmed the robustness of the model. CONCLUSION: An economic argument can be made for giving TXA to bleeding elective surgical patients. In countries where there is a blood shortage, TXA would be a cost effective way to reduce mortality. In countries where there is no blood shortage, TXA would reduce healthcare costs and avert blood borne infections

Disparities in Injury Mortality Between Uganda and the United States: Comparative Analysis of a Neglected Disease

The Author(s) 2010. This article is published with open access at Springerlink.com Background The burden of global injury-related deaths predominantly affects developing countries, which have little infrastructure to evaluate these disparities. We describe injury-related mortality patterns in Kampala, Uganda and compare them with data from the United States and San Francisco (SF), California. Methods We created a database in Kampala of deaths recorded by the City Mortuary, the Mulago Hospital Mortuary, and the Uganda Ministry of Health from July to December 2007. We analyzed the rate and odds ratios and compared them to data from the U.S. Centers for Diseas

Bioethanol Production

In recent decades, usage of biofuels as fossil fuel substitutes has increased. One method for lowering both crude oil use and environmental pollution is the production of ethanol (bioethanol) from biomass. This report offers an examination of the existing state of affairs and future prospects for biomass-to-ethanol. We examine different conversion routes from a technological, economic, and environmental standpoint. The main focus of this study is on the yield of ethanol from molasses in relation to the dilution ratio and the quantity of yeast used for fermentation while maintaining a constant fermentation temperature and time. In this investigation, the feedstock is sugarcane molasses. A thick by-product of turning sugar cane into sugar is sugarcane molasses. Consequently, sugarcane molasses and other agricultural byproducts are desirable feedstock for the manufacture of bioethanol. Agricultural wastes are cheap, abundant, and renewable. The least expensive strain for the conversion of biomass substrate is Saccharomyces cerevisiae. As a conclusion, it was found that the ethanol yield increased with an increase in yeast quantity, reaching an optimal yeast quantity before ethanol yield started to drop. The ideal ratio of molasses to water was found to be 1:2. The amount of fermentable sugars contained in the biomass has a significant impact on the output of ethanol

Key Aspects of Health Policy Development to Improve Surgical Services in Uganda

Recently, surgical services have been gaining greater attention as an integral part of public health in low-income countries due to the significant volume and burden of surgical conditions, growing evidence of the cost-effectiveness of surgical intervention, and global disparities in surgical care. Nonetheless, there has been limited discussion of the key aspects of health policy related to surgical services in low-income countries. Uganda, like other low-income sub-Saharan African countries, bears a heavy burden of surgical conditions with low surgical output in health facilities and significant unmet need for surgical care. To address this lack of adequate surgical services in Uganda, a diverse group of local stakeholders met in Kampala, Uganda, in May 2008 to develop a roadmap of key policy actions that would improve surgical services at the national level. The group identified a list of health policy priorities to improve surgical services in Uganda. The priorities were classified into three areas: (1) human resources, (2) health systems, and (3) research and advocacy. This article is a critical discussion of these health policy priorities with references to recent literature. This was the first such multidisciplinary meeting in Uganda with a focus on surgical services and its output may have relevance to health policy development in other low-income countries planning to improve delivery of surgical services

First Things First: Effectiveness and Scalability of a Basic Prehospital Trauma Care Program for Lay First-Responders in Kampala, Uganda

BACKGROUND: We previously showed that in the absence of a formal emergency system, lay people face a heavy burden of injuries in Kampala, Uganda, and we demonstrated the feasibility of a basic prehospital trauma course for lay people. This study tests the effectiveness of this course and estimates the costs and cost-effectiveness of scaling up this training. METHODS AND FINDINGS: For six months, we prospectively followed 307 trainees (police, taxi drivers, and community leaders) who completed a one-day basic prehospital trauma care program in 2008. Cross-sectional surveys and fund of knowledge tests were used to measure their frequency of skill and supply use, reasons for not providing aid, perceived utility of the course and kit, confidence in using skills, and knowledge of first-aid. We then estimated the cost-effectiveness of scaling up the program. At six months, 188 (62%) of the trainees were followed up. Their knowledge retention remained high or increased. The mean correct score on a basic fund of knowledge test was 92%, up from 86% after initial training (n = 146 pairs, p = 0.0016). 97% of participants had used at least one skill from the course: most commonly haemorrhage control, recovery position and lifting/moving and 96% had used at least one first-aid item. Lack of knowledge was less of a barrier and trainees were significantly more confident in providing first-aid. Based on cost estimates from the World Health Organization, local injury data, and modelling from previous studies, the projected cost of scaling up this program was $0.12 per capita or$25-75 per life year saved. Key limitations of the study include small sample size, possible reporter bias, preliminary local validation of study instruments, and an indirect estimate of mortality reduction. CONCLUSIONS: Lay first-responders effectively retained knowledge on prehospital trauma care and confidently used their first-aid skills and supplies for at least six months. The costs of scaling up this intervention to cover Kampala are very modest. This may be a cost-effective first step toward developing formal emergency services in Uganda other resource-constrained settings. Further research is needed in this critical area of trauma care in low-income countries

Sepsis in two hospitals in Rwanda: A retrospective cohort study of presentation, management, outcomes, and predictors of mortality.

PURPOSE: Few studies have assessed the presentation, management, and outcomes of sepsis in low-income countries (LICs). We sought to characterize these aspects of sepsis and to assess mortality predictors in sepsis in two referral hospitals in Rwanda. MATERIALS AND METHODS: This was a retrospective cohort study in two public academic referral hospitals in Rwanda. Data was abstracted from paper medical records of adult patients who met our criteria for sepsis. RESULTS: Of the 181 subjects who met eligibility criteria, 111 (61.3%) met our criteria for sepsis without shock and 70 (38.7%) met our criteria for septic shock. Thirty-five subjects (19.3%) were known to be HIV positive. The vast majority of septic patients (92.7%) received intravenous fluid therapy (median = 1.0 L within 8 hours), and 94.0% received antimicrobials. Vasopressors were administered to 32.0% of the cohort and 46.4% received mechanical ventilation. In-hospital mortality for all patients with sepsis was 51.4%, and it was 82.9% for those with septic shock. Baseline characteristic mortality predictors were respiratory rate, Glasgow Coma Scale score, and known HIV seropositivity. CONCLUSIONS: Septic patients in two public tertiary referral hospitals in Rwanda are young (median age = 40, IQR = 29, 59) and experience high rates of mortality. Predictors of mortality included baseline clinical characteristics and HIV seropositivity status. The majority of subjects were treated with intravenous fluids and antimicrobials. Further work is needed to understand clinical and management factors that may help improve mortality in septic patients in LICs

Epidemiology of injuries presenting to the national hospital in Kampala, Uganda: implications for research and policy

BackgroundDespite the growing burden of injuries in LMICs, there are still limited primary epidemiologic data to guide health policy and health system development. Understanding the epidemiology of injury in developing countries can help identify risk factors for injury and target interventions for prevention and treatment to decrease disability and mortality.AimTo estimate the epidemiology of the injury seen in patients presenting to the government hospital in Kampala, the capital city of Uganda.MethodsA secondary analysis of a prospectively collected database collected by the Injury Control Centre-Uganda at the Mulago National Referral Hospital, Kampala, Uganda, 2004-2005.ResultsFrom 1 August 2004 to 12 August 2005, a total of 3,750 injury-related visits were recorded; a final sample of 3,481 records were analyzed. The majority of patients (62%) were treated in the casualty department and then discharged; 38% were admitted. Road traffic injuries (RTIs) were the most common causes of injury for all age groups in this sample, except for those under 5 years old, and accounted for 49% of total injuries. RTIs were also the most common cause of mortality in trauma patients. Within traffic injuries, more passengers (44%) and pedestrians (30%) were injured than drivers (27%). Other causes of trauma included blunt/penetrating injuries (25% of injuries) and falls (10%). Less than 5% of all patients arriving to the emergency department for injuries arrived by ambulance.ConclusionsRoad traffic injuries are by far the largest cause of both morbidity and mortality in Kampala. They are the most common cause of injury for all ages, except those younger than 5, and school-aged children comprise a large proportion of victims from these incidents. The integration of injury control programs with ongoing health initiatives is an urgent priority for health and development

Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa