Beginning On-Line Delphi Ethnographic Research: The BOLDER Method

The use of the Internet to gather data, produce and report research has changed the face of the fields of education and research. This paper will present a method for combining electronic on-line media and Delphi methodology to begin the process of ethnographic research with participant inclusion, informed consent, data gathering by discourse facilitation, and preparation for coding. The use of a reflecting team by the research group provides impetus for second round responses by participants. Methods, format, a case study and an evaluation of the process will be presented

How complete were maternal death reviews in Central Kenya 2015 - 2018?

In response to high maternal mortality ratio (MMR) Kenya implemented mandatory maternal death reviews (MDR) in 2004. This retrospective study used MDR data to assess the completeness of MDR process in seven hospitals of Thika sub-county, central Kenya from January 2015 to June 2018. Of all 43 maternal deaths that occurred, 98% were notified while 64% were audited. MDR forms were filled in 55% of the cases of which only 7% had complete documentation. The median age of patients was 30 years majority of whom died within 24 hours of admission. Caesarean sections were associated with 48% of deaths, with haemorrhage accounting for most of the direct causes. Data on hospital-related delays, missed opportunities and action points were most frequently omitted in MDR forms. Capacity building for audit teams is recommended to improve quality of MDR process particularly focusing on identifying causes of preventable maternal deaths. Keywords: Maternal, Mortality audits, SORT-IT En réponse à un taux de mortalité maternelle élevé (TMM), le Kenya a mis en œuvre des examens obligatoires des décès maternels (MDR) en 2004. Cette étude rétrospective a utilisé des données MDR pour évaluer l'exhaustivité du processus de MDR dans sept hôpitaux du sous-comté de Thika, dans le centre du Kenya, de janvier 2015 à Juin 2018. Sur les 43 décès maternels survenus, 98% ont été notifiés tandis que 64% ont été audités. Des formulaires MDR ont été remplis dans 55% des cas, dont seulement 7% avaient une documentation complète. L'âge médian des patients était de 30 ans dont la majorité est décédée dans les 24 heures suivant l'admission. Les césariennes étaient associées à 48% des décès, les hémorragies représentant la plupart des causes directes. Les données sur les retards hospitaliers, les occasions manquées et les points d'action étaient le plus souvent omises dans les formulaires MDR. Le renforcement des capacités des équipes d'audit est recommandé pour améliorer la qualité du  processus de MDR, en se concentrant en particulier sur l'identification des causes de décès maternels évitables.  Mots-clés: Audits maternels, de mortalité, SORT-I

"They just come, pick and go." The Acceptability of Integrated Medication Adherence Clubs for HIV and Non Communicable Disease (NCD) Patients in Kibera, Kenya

Introduction The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments. METHODOLOGY: We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people's experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions. RESULTS: MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group. CONCLUSIONS: Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts

Habitat Characteristics of Northern Bobwhite Quail-Hunting Party Encounters: A Landscape Perspective

Landcover data and bobwhite hunting records were used to assess both hunter habitat preferences and the frequency of northern bobwhite encounters by hunting parties in relation to habitat composition during the 1994-1995 and 1995-1996 hunting seasons at the Joseph W. Jones Ecological Research Center in southern Georgia. Patterns of habitat use by hunters, and the frequency of bobwhite encounters varied within and between years, depending on habitat quality, food availability, and other factors. Landscape-scale analyses of standardized bobwhite covey densities (based on coveys pointed in the field) and habitat composition and configuration for the 1994-1995 hunting season revealed that bobwhite densities were: (1) positively associated with the overall percentage agriculture and food plot habitat (reaching a maximum at 30-35% agriculture); and (2) positively associated with edge complexity, and positively associated with agricultural mean patch size [reaching a maximum at 2-3 hectares (5-6 acres)]. Consequently, larger food plots may be more important for increasing bobwhite encounter rates than numerous very small food plots [ \u3c 0.1 hectares (0.25 acres)]. Results of this, and related ongoing studies, have important implications for both landscape design and multiple use resource management. activities in the context of northern bobwhite habitat management in southern upland pine forest ecosystems

Genomics reveals historic and contemporary transmission dynamics of a bacterial disease among wildlife and livestock

Whole-genome sequencing has provided fundamental insights into infectious disease epidemiology, but has rarely been used for examining transmission dynamics of a bacterial pathogen in wildlife. In the Greater Yellowstone Ecosystem (GYE), outbreaks of brucellosis have increased in cattle along with rising seroprevalence in elk. Here we use a genomic approach to examine Brucella abortus evolution, cross-species transmission and spatial spread in the GYE. We find that brucellosis was introduced into wildlife in this region at least five times. The diffusion rate varies among Brucella lineages (∼3 to 8 km per year) and over time. We also estimate 12 host transitions from bison to elk, and 5 from elk to bison. Our results support the notion that free-ranging elk are currently a self-sustaining brucellosis reservoir and the source of livestock infections, and that control measures in bison are unlikely to affect the dynamics of unrelated strains circulating in nearby elk populations

The secreted protein Cowpox Virus 14 contributes to viral virulence and immune evasion by engaging Fc-gamma-receptors

The genome of cowpoxvirus (CPXV) could be considered prototypical for orthopoxviridae (OXPV) since it contains many open reading frames (ORFs) absent or lost in other OPXV, including vaccinia virus (VACV). These additional ORFs are non-essential for growth in vitro but are expected to contribute to the broad host range, virulence and immune evasion characteristics of CPXV. For instance, unlike VACV, CPXV encodes proteins that interfere with T cell stimulation, either directly or by preventing antigen presentation or co-stimulation. When studying the priming of naïve T cells, we discovered that CPXV, but not VACV, encodes a secreted factor that interferes with activation and proliferation of naïve CD8+ and CD4+ T cells, respectively, in response to anti-CD3 antibodies, but not to other stimuli. Deletion mapping revealed that the inhibitory protein is encoded by CPXV14, a small secreted glycoprotein belonging to the poxvirus immune evasion (PIE) family and containing a smallpoxvirus encoded chemokine receptor (SECRET) domain that mediates binding to chemokines. We demonstrate that CPXV14 inhibition of antibody-mediated T cell activation depends on the presence of Fc-gamma receptors (FcγRs) on bystander cells. In vitro, CPXV14 inhibits FcγR-activation by antigen/antibody complexes by binding to FcγRs with high affinity and immobilized CPXV14 can trigger signaling through FcγRs, particularly the inhibitory FcγRIIB. In vivo, CPXV14-deleted virus showed reduced viremia and virulence resulting in reduced weight loss and death compared to wildtype virus whereas both antibody and CD8+ T cell responses were increased in the absence of CPXV14. Furthermore, no impact of CPXV14-deletion on virulence was observed in mice lacking the inhibitory FcγRIIB. Taken together our results suggest that CPXV14 contributes to virulence and immune evasion by binding to host FcγRs

Conflict and tuberculosis in Sudan: a 10-year review of the National Tuberculosis Programme, 2004-2014

Background Sudan is a fragile developing country, with a low expenditure on health. It has been subjected to ongoing conflicts ever since 1956, with the Darfur crisis peaking in 2004. The conflict, in combination with the weak infrastructure, can lead to poor access to healthcare. Hence, this can cause an increased risk of infection, greater morbidity and mortality from tuberculosis (TB), especially amongst the poor, displaced and refugee populations. This study will be the first to describe TB case notifications, characteristics and outcomes over a ten-year period in Darfur in comparison with the non-conflict Eastern zones within Sudan. Methods A cross-sectional review of the National Tuberculosis Programme (NTP) data from 2004 to 2014 comparing the Darfur conflict zone with the non-conflict eastern zone. Results New case notifications were 52% lower in the conflict zone (21,131) compared to the non-conflict zone (43,826). Smear-positive pulmonary TB (PTB) in the conflict zone constituted 63% of all notified cases, compared to the non-conflict zone of 32% (p < 0.001). Extrapulmonary TB (EPTB) predominated the TB notified cases in the non-conflict zone, comprising 35% of the new cases versus 9% in the conflict zone (p < 0.001). The loss to follow up (LTFU) was high in both zones (7% conflict vs 10% non-conflict, p < 0.001) with a higher rate among re-treatment cases (12%) in the conflict zone. Average treatment success rates of smear-positive pulmonary TB (PTB), over ten years, were low (65-66%) in both zones. TB mortality among re-treatment cases was higher in the conflict zone (8%) compared to the non-conflict zone (6%) (p < 0.001). Conclusion A low TB case notification was found in the conflict zone from 2004 to 2014. High loss to follow up and falling treatment success rates were found in both conflict and non-conflict zones, which represents a significant public health risk. Further analysis of the TB response and surveillance system in both zones is needed to confirm the factors associated with the poor outcomes. Using context-sensitive measures and simplified pathways with an emphasis on displaced persons may increase access and case notification in conflict zones, which can help avoid a loss to follow up in both zones