The Immunology of Asthma and Allergic Rhinitis

The immune system is a complex collection of cells, tissues, and chemical mediators positioned throughout the body, whose primary purpose is to protect us against infection. However, its function is not only fundamental in protection from infectious disease but also provides aberrant response in allergens such as with asthma and allergic rhinitis. Allergic diseases like asthma and allergic rhinitis are characterized by a distinct type of inflammatory response, driven by immunoglobulin E (IgE)-dependent mechanisms. In asthma and allergic rhinitis, the inflammatory response is mediated by interaction of several immune cells (monocytes, lymphocytes, and polymorphonuclear cells) and cellular chemical mediators. In particular, atopic allergic response leads to destruction of multiple target cells such as epithelial, parenchymal and vascular and connective tissue of the airways. In addition, in inflammatory response in asthma and allergic rhinitis, sensory nerves are sensitized, leading to clinical manifestations. Sneezing and coughing are hypersensitivity responses of sensory nerves in allergic rhinitis and asthma, respectively. Similarly, nasal congestion and discharge in allergic rhinitis are due to vasodilatation that leads to plasma exudates as well as mucous secretion. The allergic inflammatory response is regulated by several transcription factors, particularly nuclear factor-κb (NF-κB), GATA-3 protein 3, and GATA binding protein

Implications of antibiotic exposure among children in low-income and middle income countries

Günther Fink and colleagues are to be congratulated for their analysis of antibiotic exposure among children younger than 5 years in low-income and middle-income countries (LMICs) with a range of common illnesses, including cough, fever, diarrhoea, and malaria.1 The authors explain that their study1 is the first to use a robust method to comprehensively quantify cumulative antibiotic exposure among children in LMICs by obtaining nationally representative data from surveys of households and formal-sector health-care facilities. Quantifying exposure is important, as previous surveys have only had limited coverage in low-income settings, particularly in sub-Saharan African countries, which have the highest incidence of infectious diseases globally.2,3 However, quantifying true antibiotic use in LMICs might be difficult if antibiotics are frequently purchased without a prescription due to issues with affordability and access. Obtaining antibiotics in this way accounts for up to 93% of all antibiotics dispensed in some LMICs.4,5 The remaining 7% or more include antibiotics obtained from ambulatory care and inpatient hospital care.2 Antimicrobial resistance is a growing publi

Compliance to prescribing guidelines among public health care facilities in Namibia : findings and implications

Background: The World Health Organization estimates that over 50% medicines are prescribed inappropriately and the main driver of antimicrobial resistance globally. There have only been a limited number of studies evaluating prescribing patterns against national Standard Treatment Guidelines (STGs) in sub-Saharan African countries including Namibia. This is important given the high prevalence of both infectious and non-infectious diseases in sub-Saharan Africa alongside limited resources. Objective: Our aim was to assess prescribing practices and drivers of compliance to National guidelines among public health care facilities in Namibia to provide future guidance. Setting: Three levels of public healthcare in Namibia. Method: A mixed method approach including patient exit and prescriber interviews at three levels of health care in Namibia, i.e. hospital, health centre and clinic. Main outcome measures: Medicine prescribing indicators, compliance to and attitudes towards National guidelines. Results: Of the 1,243 prescriptions analysed, 73% complied with the STGs and 69% had an antibiotic. Of the 3759 medicines (i.e. mean of 3.0±1.1) prescribed, 64% were prescribed generically. The vast majority of prescribers were aware of, and had access to, the Namibian STGs (94.6%), with the majority reporting that the guidelines are easy to use and they regularly refer to them. The main drivers of compliance to guidelines were programmatic, that is access to up-to date objective guidelines, support systems for continued education on their use, and ease of referencing. Lack of systems to regulate noncompliance impacted on their use. Conclusion: Whilst the findings were encouraging, ongoing concerns included limited prescribing of generic medicines and high use of antibiotics. A prescribing performance management system should be introduced to improve and monitor compliance to prescribing guidelines in public healthcare

A qualitative evaluation of compliance to prescribing guidelines in public health care facilities in Namibia

Background: The World Health Organisation estimates that over 50% medicines are prescribed inappropriately and the main driver of antimicrobial resistance globally. There have only been a limited number of studies evaluating prescribing patterns in Namibia as the country strives to continue to provide comprehensive healthcare; majority using quantitative methods. Consequently, there is a need to address this. The objective is to evaluate prescribing practices among public health care facilities in Namibia to provide future guidance. Methods: A mixed methods medicines use evaluation was conducted to assess compliance to guidelines. Qualitative methods used to evaluate factors and practices associated with prescribing at three levels of health care, i.e. hospital, health centre and clinic. Main outcome measures for the quantitative study were compliance to current standard treatment guidelines (STGs),85% compliance to STGs is considered acceptable. Results: Of the 1,243 prescriptions, 73% complied with the STGs and 69% had an antibiotic. Of the 3759 medicines (mean of 3.0±1.1 per prescription) prescribed, 64% had generic names. 94.6% of prescribers were aware and had access to STGs for reference purposes, with 82% reporting easy to use NSTG. Main thematic factors driving compliance to therapeutic guidance were programmatic, that is access to up-to date objective guidelines, continued education on their use, and ease of referencing using an index. Lack of systems to regulate noncompliance impacted on their use. Conclusion: Given concerns with adherence to guidelines, lack of INN prescribing and high use of antibiotics, a prescribing performance management system should be introduced in Namibia to improve prescribing. This will be monitored

Quality assurance of health management information system in Kayunga district, Uganda

Background: An efficient health management information system (HMIS) improves health care delivery and outcomes. However, in most rural settings in Uganda, paper-based HMIS are widely used to monitor public health care services. Moreover, there are limited capabilities and capacity for quality HMIS in remote settings such as Kayunga district. Objectives: The quality assurance practices of HMIS in health centres (HCs) in Kayunga district were evaluated. Method: A cross-sectional descriptive study design was used to assess the quality of HMIS at 21 HCs in Kayunga district. Data were collected through in-depth interviews of HMIS focal persons as well as document analysis of HMIS records and guidelines between 15 June 2010 and 15 July 2010. The main outcomes were quality assurance practices, the HMIS programmatic challenges and opportunities. The practice of HMIS was assessed against a scale for good quality assurance practices. Qualitative data were coded and thematically analysed, whereas quantitative data were analysed by descriptive statistics using SPSS v22 software. Results: All the 21 HCs had manual paper-based HMIS. Less than 25% of HCs practised quality assurance measures during collection, compilation, analysis and dissemination of HMIS data. More than 50% of HCs were not practising any type of quality assurance during analysis and dissemination of data. The main challenges of the HMIS were the laborious and tedious manual system, the difficulty to archive and retrieve records, insufficient HMIS forms and difficulty in delivering hard copies of reports to relevant stakeholders influenced quality of data. Human resource challenges included understaffing where 43% of participating HCs did not have a designated HMIS staff. Conclusion: The HMIS quality assurance practices in Kayunga were suboptimal. Training and support supervision of HMIS focal persons is required to strengthen quality assurance of HMIS. Implementation of electronic HMIS dashboards with data quality checks should be integrated alongside the manual system

Prevalence of self-medication for acute respiratory infections in Namibia : findings and implications

Background: Acute respiratory infections (ARIs) are a leading cause of morbidity and mortality among under-fives. However, self-medication and “self-care” care practices remain common especially among informal settlements in Namibia. Consequently, we sought to ascertain the rationale for this to guide future activities. Method: Mixed method approach among residents in an informal settlement in Namibia to determine the extent of health seeking behaviors and the rationale for any self-medication. Results: Of the 100 informal households surveyed, 60% used self-medication for ARIs including cold/flu medication, paracetamol and decongestants. There was no self-purchasing of antibiotics. The main drivers of self-medication were a perceived diagnosis of ARI as “minor or mild” as well as long waiting times and queues to receive care at public health facilities. Conclusion: The majority of households in this settlement self-medicate for ARIs. There is need for outreach primary health care services in the future in townships to screen and appropriately manage ARI to address concerns. This can include increasing pharmacy services

Utility of medicines information leaflets in hypertensive care in a setting with low health literacy : a cross-sectional study

Introduction: Higher levels of health literacy improve utilization of health information, medication adherence and outcomes. Few studies evaluate the utility of medicines information in hypertensive care in settings with low health literacy. Aim: To determine the level of health literacy and utility of medicines information leaflets (MIL) among hypertensive patients in public health care in Namibia.Methods: A hospital-based survey among hypertensive patients receiving care at a referral hospital in Namibia from the 8th to 29thJune 2018. Patient’s health literacy and utility of MIL were assessed using three literacy tools and a survey questionnaire. Quantitative data were analysed using descriptive statistics and qualitative thematic content analysis for factors associate with the utility of the MIL. Results: Of the 139 patients, 63% were female and the mean age was 45.7(range: 19.0-84.0) years. Over 85.6% had of low literacy skills (REALM score<44, i.e. unable to read simple health materials), 38.8% had positive SILS scores (≥2, require help to read medicines information) and 66.9% had inadequate skills for comprehension, appraisal and decision-making with regard to health information (HLSI-SF score <70%). The level of access to and utility of MIL were low, 32.4% and 34.6% respectively. The main factors associated with poor utility of the MIL were low patient health literacy, lack of guidelines on the use of MIL and MIL written in non-native languages. Conclusion: Low rates of health literacy and utility of MIL were observed among hypertensive patients in Namibia. The integration of health literacy programmes, and MIL guidelines are needed to promote utility of medicine information and improve medication adherence

Consumption of psychotropic medicines at a referral hospital in Namibia: findings and implications

Setting: In Namibia, the burden of mental illnesses is estimated at 25.6% and is expected to double by 2025. Few studies in sub-Saharan Africa estimate the consumption rates of psychotropic medicines as a proxy of irrational use. Aim: The consumption rate of psychotropic medicines at a referral hospital was determined. Method: A hospital-based retrospective medicine utilization analysis of Facility Electronic Stock Card (FESC) psychotropic medication was conducted at Intermediate Hospital Katutura over a 7 year period, 2011-2017. Data on consumption and expenditure on psychotropic medicines were abstracted from FESC and analysed using descriptive statistics in SPSS v22. The main outcomes were consumption rates, daily Defined Dose, (DDD) and/or expenditure. Results: Of the 580 351,4 DDD of psychotropic medicines consumed, 84% were anti-psychotics, 9.2% anti-depressants and 6.8% anxiolytics. Anti-psychotics (48.8%) and anxiolytics (47.9%) had the highest consumption by cost relative to antidepressants (3.3%). The most consumed antidepressants were imipramine (62%) by DDD and fluoxetine (55.8%) by cost. The most consumed anti-psychotics were chlorpromazine (74.6%) by DDD and haloperidol (68.4%) by cost respectively. Diazepam (79.4%) and hydroxyzine (94.2%) were most consumed sedative-hypnotics by DDD and cost respectively. Conclusion: The consumption of new psychotropics contributes to higher costs. There is need for cost-effectiveness analysis of new versus conventional psychotropics to optimize treatment, outcomes and costs

The Potential Effect of Using the Cockcroft-Gault Method on Tenofovir-Associated Renal Impairment Reports and on Clinical Decisions Regarding Tenofovir Use in Individual Patients: Implications for the Future

Introduction: In Namibia, the Cockcroft-Gault (C-G) method is recommended for monitoring renal function in HIV patients receiving tenofovir disoproxil fumarate (TDF)-containing combination antiretroviral therapy (cART). However, there are concerns with the potential over-reporting of TDF-associated renal impairment. Methods: Retrospective study comparing the renal function of patients receiving 2nd line cART with either C-G or Chronic Kidney Disease-Epidemiology (CKD-EPI) methods. Results: 71 patients were included. The majority (62%) received TDF-containing 1st line ART. All received 2nd-line cART containing TDF/ lamivudine (3TC)/ zidovudine (AZT) and LPV/r. Before switching to 2nd-line cART, 40.8% and 8.5% had abnormal eGFR according to C-G and CKD-EPI methods respectively. During 2nd-line cART, 47.9% and 7% of patients had abnormal eGFR by C-G and CKD-EPI methods, respectively, and 4.1% and 2.8% respectively experienced a decline in eGFR. There was a significant lack of agreement between the two methods. Conclusion: The C-G method has the potential to report more cases of TDF-associated renal impairment. Consequently, national guidelines in Namibia and other pertinent countries should be reviewed if this is the recommended method for monitoring renal function

Analysis of policies for the utilization of important antibiotics in animals in Nambia and the implications for future antimicrobial stewardship

Background: Globally, the overuse of medically important antibiotics in animals is common and a considerable driver of antimicrobial resistance (AMR) with implications on mortality and costs. Consequently, among African countries with high AMR rates there is a need to analyse policies and resistance patterns with the ongoing use of medically important antibiotics in animals. The findings can be used to guide future policies. Methods: Descriptive analysis of the appropriateness of policies and their current impact on resistance patterns of medically important antibiotics in Namibia against the WHO AWaRe guidance on antimicrobial stewardship. Results: Out of the 45 medically important antibiotics currently registered for use in animals in Namibia, 77.8% are in the AWaRe Access category, 68.9% are broad-spectrum and 60% are non-prescription – mainly tetracyclines, penicillins and sulphonamides. Consequently, there is currently misalignment in policies for human and animal use in Namibia alongside global recommendations. There is also currently no guideline for the use of antibiotics in animals in Namibia. Most medically important antibiotics that are currently being used are indicated for control of gastrointestinal (77.7%), musculoskeletal (71.1%) and respiratory (46.7%) infections in addition to growth promotion (4.4%). Resistance is high among humans to commonly used AWaRe Access antibiotics including penicillin (13.5%-100%), sulphonamides (19.5%-100%) and tetracyclines (56%-100%). Conclusion: Whilst Namibia has banned the use of antibiotics in farming, current policies are not aligned to global AWaRe guidance, and promote the overuse of broad-spectrum antibiotics. This needs addressing in a multi-sectoral one health coalition alongside advancing antimicrobial stewardship