Point-of-Care Diagnostics for Infection and Antimicrobial Resistance in Sub-Saharan Africa - A Narrative Review.

INTRODUCTION Sub-Saharan African (SSA) countries are severely impacted by antimicrobial resistance (AMR). Due to gaps in access to diagnostics in SSA the true extent of AMR remains unknown. This diagnostic gap affects patient management and leads to significant antimicrobial overuse. This review explores how point-of-care (POC) testing for pathogen identification and AMR may be used to close the diagnostic gap in SSA countries. METHODS A narrative review exploring current clinical practice and novel developments in the field of point-of-care (POC) testing for infectious diseases and AMR. FINDINGS POC assays for identification of various pathogens have been successfully rolled out in SSA countries. While implementation studies have mostly highlighted impressive test performance of POC assays, there is limited data on effect of implementation on clinical outcomes and cost-effectiveness. We did not encounter local studies of host-directed POC assays relevant to AMR. Novel POC assays using real-time PCR, isothermal amplification, microfluidics and other technologies are in various stages of development. DISCUSSION Available literature shows that POC testing for AMR applications is implementable in SSA and holds the potential to reduce the diagnostic gap. Implementation will require effective regulatory pathways, incorporation of POC testing in clinical and laboratory guidelines, and adequate value capture in existing health financing models

The use of imagery in global health: an analysis of infectious disease documents and a framework to guide practice

We report an empirical analysis of the use of imagery by the key actors in global health who set policy and strategy, and we provide a comprehensive overview, particularly related to images used in reports on vaccination and antimicrobial resistance. The narrative currently depicted in imagery is one of power imbalances, depicting women and children from low-income and middle-income countries (LMICs) with less dignity, respect, and power than those from high-income countries. The absence of any evidence of consent for using intrusive and out-of-context images, particularly of children in LMICs, is concerning. The framework we have developed provides a platform for global health actors to redefine their intentions and recommission appropriate images that are relevant to the topic, respect the integrity of all individuals depicted, are accompanied by evidence of consent, and are equitable in representation. Adhering to these standards will help to avoid inherent biases that lead to insensitive content and misrepresentation, stigmatisation, and racial stereotyping

Predictors of late presentation for obstetric fistula repair in Abakaliki, South-East Nigeria

Late presentation is a challenge to reducing the backlog of obstetric fistulas. We aimed to identify characteristics of women presenting late for repair in order to improve patient recruitment. It was a cross-sectional comparative study. Data was collected from the women and the hospital notes using proforma and analysed using SPSS. Associations between categorical variables were determined using Chi-square. Predictors of late presentation were determined using logistic regression. A P-value of <0.05 was statistically significant. The mean time of presentation was 42.3 months. Late presentation was significantly associated with age >35 years, parity < 3, not having a spouse, and trauma. On logistic regression, women aged 35 years and above were five times more likely to present late compared with younger ones (AOR= 5.192, 95%CI 1.839-14.660, P=0.002), while women with parity >3 were five times less likely to present late compared with those <3 (AOR= 0.208, 95%CI 0.073-0.587, P=0.003). In conclusion, most patients presented late. Although age, parity, having a spouse, and aetiology were associated with time of presentation, age >35 years and parity < 3 were the significant predictors of late presentation. Recruitment for early repair should be a priority area of the national policy for the elimination of obstetric fistula.   La présentation tardive est un défi pour réduire l'arriéré des fistules obstétricales. Nous avons cherché à identifier caractéristiques des femmes se présentant tardivement pour réparation afin d'améliorer le recrutement des patientes. Il s'agissait d'une étude comparative transversale. Les données ont été recueillies auprès des femmes et des notes d'hôpital à l'aide de formulaires proforma. et analysés à l'aide de SPSS. Les associations entre les variables catégorielles ont été déterminées à l'aide du Chi carré. Les prédicteurs de présentation tardive ont été déterminés à l'aide de la régression logistique. Une valeur p de <0,05 était statistiquement significatif. Le délai moyen de présentation était de 42,3 mois. La présentation tardive était significativement associé à l'âge > 35 ans, la parité < 3, l'absence de conjoint et un traumatisme. En régression logistique, les femmes âgés de 35 ans et plus étaient cinq fois plus susceptibles de se présenter tardivement que les plus jeunes (AOR = 5,192, IC à 95 % 1,839-14,660, P=0,002), tandis que les femmes avec une parité >3 étaient cinq fois moins susceptibles de présenter en retard par rapport à ceux <3 (AOR = 0,208, IC à 95 % 0,073-0,587, P = 0,003). En conclusion, la plupart des patients présenté tardivement. Bien que l'âge, la parité, le fait d'avoir un conjoint et l'étiologie soient associés au temps de la présentation, l'âge > 35 ans et la parité < 3 étaient les prédicteurs significatifs de la présentation tardive. Recrutement la réparation précoce devrait être un domaine prioritaire de la politique nationale d'élimination de la fistule obstétricale

Interventional research to tackle antimicrobial resistance in Low Middle Income Countries in the era of the COVID-19 pandemic: lessons in resilience from an international consortium

This article summarizes the consequences of the COVID-19 pandemic, on an international project to tackle antimicrobial resistance (AMR). The research leadership and process, the access to data, and stakeholders were deeply disrupted by the national and international response to the pandemic, including the interruption of healthcare delivery, lockdowns, and quarantines. The key principles to deliver the research through the pandemic were mainly the high degree of interdisciplinary engagement with integrated teams, and equitable partnership across sites with capacity building and leadership training. The level of preexisting collaboration and partnership were also keys to sustaining connections and involvements throughout the pandemic. The pandemic offered opportunities for realigning research priorities. Flexibility in funding timelines and projects inputs are required to accommodate variance introduced by external factors. The current models for research collaboration and funding need to be critically evaluated and redesigned to retain the innovation that was shown to be successful through this pandemic

What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course

Copyright © The Author(s) 2021. Background: Whilst antimicrobial stewardship (AMS) is being implemented globally, contextual differences exist. We describe how the use of a massive open online course (MOOC) platform provided an opportunity to gather diverse narratives on AMS from around the world. Methods: A free 3 week MOOC titled ‘Tackling antimicrobial resistance: a social science approach’ was launched in November 2019. Learners were asked specific questions about their experiences of AMS via 38 optional free-text prompts dispersed throughout the modules. Content analysis was used to identify key emerging themes from the learners’ responses in the first three runs of the MOOC. Results: Between November 2019 and July 2020, 1464 learners enrolled from 114 countries. Overall, 199 individual learners provided a total of 1097 responses to the prompts. The diverse perspectives describe unique challenges present in different contexts including ill-defined roles for pharmacists and nurses in AMS; inadequate governance and policy inconsistencies in surveillance for antibiotic consumption and antimicrobial resistance (AMR) in some countries; lack of ownership of antibiotic decision-making and buy-in from different clinical specialties; and human resource and technological constraints. Patients’ knowledge, experiences and perspectives were recognized as a valuable source of information that should be incorporated in AMS initiatives to overcome cultural barriers to the judicious use of antibiotics. Conclusions: Analysis of learner comments and reflections identified a range of enablers and barriers to AMS implementation across different healthcare economies. Common challenges to AMS implementation included the role of non-physician healthcare workers, resource limitations, gaps in knowledge of AMR, and patient engagement and involvement in AMS.NIHR Imperial Patient Safety Translational Research Centre (PSTRC-2016-004); Economic and Social Research Council (ESRC) (Grant number: ES/P008313/1); associated projects, which include The National Institute for Health Research Antibiotic use across Surgical Pathways: Investigating, Redesigning and Evaluating Systems (ASPIRES) project (https://www.imperial.ac.uk/arc/aspires/) and Improve uptake and SusTainability of Effective interventions to promote Prudent antibiotic Use in Primary care (STEP-UP) project (https://www.expmedndm.ox.ac.uk/step-up/)

Survey of healthcare worker perceptions of changes in infection control and antimicrobial stewardship practices in India and South Africa during the COVID-19 pandemic

OBJECTIVE: To identify perceptions and awareness of changes in infection prevention and control (IPC) and antimicrobial stewardship (AMS) practices among healthcare workers (HCWs) during the COVID-19 pandemic in India and South Africa (SA). METHOD: A self-administered online survey which included participant demographics, knowledge and sources of COVID-19 infection, perceived risks and barriers, and self-efficacy. Data were analysed using descriptive statistics. RESULTS: The study received 321 responses (response rate: 89.2%); 131/321 (40.8%) from India and 190/321 (59.2%) from SA; male to female response rate was 3:2, with majority of respondents aged 40-49 (89/321, 27.7%) and 30-39 (87/321, 27.1%) years. Doctors comprised 47.9% (57/119) of respondents in India and 74.6% (135/181) in SA. Majority of respondents in India (93/119, 78.2%) and SA (132/181, 72.9%) were from the private and public sectors, respectively, with more respondents in SA (123/174, 70.7%) than in India (38/104, 36.5%) involved in antimicrobial prescribing.Respondents reported increased IPC practices since the pandemic and noted a need for more training on case management, antibiotic and personal protective equipment (PPE) use. While they noted increased antibiotic prescribing since the pandemic, they did not generally associate their practice with such an increase. A willingness to be vaccinated, when vaccination becomes available, was expressed by 203/258 (78.7%) respondents. CONCLUSIONS: HCWs reported improved IPC practices and changes in antibiotic prescribing during the COVID-19 pandemic. Targeted education on correct use of PPE was an identified gap. Although HCWs expressed concerns about antimicrobial resistance, their self-perceived antibiotic prescribing practices seemed unchanged. Additional studies in other settings could explore how our findings fit other contexts

What does antimicrobial stewardship look like where you are? Global narratives from participants in a Massive Open Online Course

Introduction Whilst Antimicrobial Stewardship (AMS) is being implemented in different countries, different contexts continue to present unique challenges. We investigated the challenges to implementing AMS in different countries by examining comments from clinical, academic, and lay learners participating in a Massive Open Online Course (MOOC) on tackling antimicrobial resistance (AMR). Methods A 3-week MOOC titled “Tackling AMR: A social science approach” was developed with a global faculty in collaboration with the British Society of Antimicrobial Chemotherapy and Imperial College London and launched in November 2019. Learners were asked specific questions about their experiences of AMS throughout the MOOC which included 38 optional free text prompts. Learners' free text responses from first three-course runs (November 2019 – July 2020) were collated and coded in NVivo 12 using a conventional content analysis approach to identify challenges to implementing AMS across countries. Results Representing 114 countries, 1464 learners enrolled, with largest representation from the United Kingdom, India, Nigeria, Australia, and Pakistan. The learners described a range of AMS activities and team compositions. While recognising the importance of pharmacist and nurse roles in AMS, the learners reported that such roles remain ill-defined across countries, restricting the reach and potential of AMS strategies. A range of challenges to implementing AMS were described, including: limited awareness and engagement by the general public and healthcare workers (HCW) on the impact of AMR on human health, lack of adequate of governance and policy; inconsistencies in surveillance for antibiotic consumption and AMR, impeding feedback loops and improvement processes; human resource and technological constraints; variable access to key antibiotics; lack of ownership of antibiotic decision-making and buy-in from different clinical specialties. Patients’ knowledge, experiences and perspectives were recognised as a valuable source of information that needed to be incorporated in AMS initiatives to overcome cultural barriers to the judicious use of antibiotics. Conclusion Analysis of learner comments and reflections identified a range of enablers and barriers to AMS implementation across different healthcare economies. Common challenges to AMS implementation included the role of non-physician health care professionals, resources, knowledge of AMR and patient engagement and involvement in AMS

Health-seeking behaviours of older black women living with non-communicable diseases in an urban township in South Africa

BACKGROUND: Various studies have shown that non-communicable diseases (NCDs) especially diabetes and hypertension are prevalent among older women living in South African urban areas, placing a heavy burden on the healthcare system. This study aimed to understand the health-seeking behaviour, healthcare practices and prevalence of traditional herbal medicine (THM) use among older women self-reporting NCDs from the Prospective Urban Rural Epidemiology study (PURE). METHOD: A homogenous purposive sampling of PURE participants was used to recruit women who were 50 years or older (n = 250). Descriptive statistics were used to examine the number of NCDs reported by the study sample, health seeking behaviour and practices as well as THM use. Logistic regression was also employed to investigate possible associations between reported conditions and THM use or medical pluralism. RESULTS: Within the study sample, 72 % self-reported an NCD. Of those with self-reported NCDs, 46 % had one, and 54 % had two or more NCDs. Those with NCDs usually visited public clinics (80 %), relied on doctors (90 %) and nurses (85 %) for health information, and mostly used conventional medicine (CM) to manage high blood pressure (81 %). About 30 % of those with NCDs indicated using THM, of whom 29 (53 %) reported practicing medical pluralism. Participants with dental problems (OR: 3.24, 95 % CI: 1.30–8.20), headaches (OR: 2.42, 95 % CI: 1.24–4.94), heart burn (OR: 2.30, 95 % CI: 1.18–4.48) and severe tiredness (OR: 2.05, 95 % CI: 1.08–3.99) were more likely to use THM. Anxiety and allergies increased the likelihood to practise medical pluralism by five and 20 times, respectively. CONCLUSION: Self-reported NCD with co-morbidities was prevalent among the participants in the study. Most of the study participants utilized state-owned clinics and hospitals for the management of their chronic conditions. THM use was not very common. However, among those who used THM, medical pluralism was prevalent. Family history was the most common reason for THM use, with many THM patrons utilizing these for treatment of a health condition. Older black women with anxiety and allergies were more likely to practise medical pluralism