Geospatial analysis and impact of targeted development of breast cancer care in The Gambia: a cross-sectional study

Background The Gambia has one of the lowest survival rates for breast cancer in Africa. Contributing factors are late presentation, delays within the healthcare system, and decreased availability of resources. We aimed to characterize the capacity and geographic location of healthcare facilities in the country and calculate the proportion of the population with access to breast cancer care. Methods A facility-based assessment tool was administered to secondary and tertiary healthcare facilities and private medical centers and clinics in The Gambia. GPS coordinates were obtained, and proximity of service availability and population analysis were performed. Distance thresholds of 10, 20, and 45 km were chosen to determine access to screening, pathologic diagnosis, and surgical management. An additional population analysis was performed to observe the potential impact of targeted development of resources for breast cancer care. Results All 102 secondary and tertiary healthcare facilities and private medical centers and clinics in The Gambia were included. Breast cancer screening is mainly performed through clinical breast examination and is available in 52 facilities. Seven facilities provide pathologic diagnosis and surgical management of breast cancer. The proportion of the Gambian population with access to screening, pathologic diagnosis, and surgical management is 72, 53, and 62%, respectively. A hypothetical targeted expansion of resources would increase the covered population to 95, 62, and 84%. Conclusions Almost half of the Gambian population does not have access to pathologic diagnosis and surgical management of breast cancer within the distance threshold utilized in the study. Mapping and population analysis can identify areas for targeted development of resources to increase access to breast cancer care

The Quality of Intra-Partum Care in a Gambian Rural Major Health Centre

Background: The health of women and children remain to be a major challenge in the world, particularly in developing countries. It has been proven that rendering quality maternity care means providing care that is evidence-based, and practices that are have proven to be effective need to be encouraged. The instrument for the non-participant observation aimed to collect information on practices performed on laboring women from admission to discharge. This was compared with the World Health Organization Technical Working Group’s categorization on Normal Birth. Direct observation of laboring women with established normal labour and review of records of those observed was conducted for the quantitative paper. Women’s views were explored using the different interview guides: one for the exit interview, the other for the focus group discussion. The women were asked about the care they receive, perception on quality of care; on the environment of the delivery ward; and on the health care providers; and what will be their recommendations for better quality of care for women who come for labour and delivery care. The in-depth interview for health care providers was to know what are their views and perceptions of quality of care and the use of evidence-based practices; and also their suggestive recommendations for improvement. An assessment of facility’s readiness for emergency obstetric care was conducted, exploring the various service areas of the facility that have a link with labour and delivery, with the maternity unit included in this assessment. A staff audit was also conducted with special focus on health workers who are assigned to the delivery ward. OBJECTIVES: To assess practices and quality of delivery care during normal childbirth in Soma Major Health Centre in The Gambia. MATERIALS AND METHODS: The study was both a retrospective and prospective cross-sectional design combining both quantitative and qualitative methods. Maternity service data for the previous year (2010) was explored. A total of 101 labouring women were observed as part of the quantitative part. A total of fifteen post-partum women who were not part of the non-participant observation were interviewed, whereas twenty post-partum women who were not also part of the non-participant observation were invited to a focus group discussion. In-depth interview guide and focus group discussion guide were used. A total of eleven health care providers were also invited to an in-depth interview on a one-on-one basis. These health care providers work in the delivery ward, although two of these care providers who had one time worked in the delivery ward but currently assigned to the Reproductive and Child Health Clinic of the facility were also included. An interview guide was used for health care providers too. RESULTS: All women [101] were instructed to be in lithotomy position during delivery. Examination of the placenta was found to be low, 20 [19%], women allowed to take oral fluids was found in 50 [49%] of the women observed. The parenteral prophylactic use of oxytocin was found to be 62 [61%], whereas that of ergometrine use was 29 [28%]. Manual exploration of the uterus was found to be common, observed in 81 [80%] of the 101 deliveries, which is not in line with evidence. Although assessment of vital observations for blood pressure and temperature taking and recording was found to be high, the use of the partograph throughout the labour process was found to be very low [13, n=101]. Routine episiotomy was given to 29 [28%] women, out of whom 28 were primi-parous women. Infection control practices through application of the universal precautions and health care provider giving of information on results of examination were found to be infrequent. Unfortunately in 99% [n = 101] of the deliveries observed, the instruments were regarded unsterile. Information on results of examination at time of admission was observed in only 3 [n =101] of the women. Baby placed on the abdomen of the mother immediately after delivery was found to be very low, 15 [n =101]. Practices which are clearly harmful or ineffective and should be eliminated were common in this study; therefore most practices were not evidence-based, although there seem to be a high awareness amongst health care providers on these evidence-based intra-partum care practices. Problems of staff attitudes, poor communication /interpersonal skills, inadequate midwives, insufficient resources, supplies, equipment; medicines for maternity care have been mentioned by both the health care providers and women. CONCLUSION: In the overall, it may be concluded that most practices in this delivery ward are not evidence-based, and care is substandard

Intradermal administration of fractional doses of the inactivated poliovirus vaccine in a campaign: a pragmatic, open-label, non-inferiority trial in The Gambia.

BACKGROUND: A rapid increase in circulating vaccine-derived poliovirus type 2 outbreaks, and the need to reserve inactivated poliovirus vaccine (IPV) for routine immunisation, has increased the value of fractional dose IPV (fIPV) as a measure to prevent acute flaccid paralysis. However, the intradermal route of administration has been viewed as prohibitive to outbreak response campaigns. We aimed to establish the immunogenicity and safety of administering intradermal fIPV with a disposable syringe jet injector (DSJI) or an intradermal adaptor (IDA) compared with standard administration with a BCG needle and syringe (N&S). METHODS: This pragmatic, non-inferiority trial was undertaken in a campaign setting in communities in The Gambia. Children aged 4-59 months without contraindication to vaccination were eligible. Children were not individually randomly assigned; instead, the vaccination teams were randomly assigned (1:1:1) to one of three administration methods. Parents and the field team were not masked, but laboratory personnel were masked. Baseline demographic and anthropometric data were collected from the participants. Public health officers experienced at intradermal immunisation, and nurses without experience, had 2 h of training on each of the administration methods before the campaign. Participants were vaccinated using the administration method in use by the vaccination team in their community. Poliovirus serum neutralising antibodies (SNA) were measured in children aged 24-59 months before and 4 weeks after vaccination. Adverse events and data on injection quality were collected from all participants. The primary outcome was the type 2 immune response rate (seroconversion in seronegative [SNA titre <8] children plus a 4-fold titre rise in seropositive children). Adjusted differences in the immune response between the DSJI or IDA group versus the N&S group were calculated with 97·5% CIs. A margin of -10% was used to define the non-inferiority of DSJI or IDA compared to N&S. Immunogenicity analysis was done per protocol. The trial is registered with ClinicalTrials.govNCT02967783 and has been completed. FINDINGS: Between Oct 28 and Dec 29, 2016, 3189 children aged 4-59 months were recruited, of whom 3170 were eligible. Over 3 days, 2720 children were vaccinated (N&S, 917; IDA, 874; and DSJI, 929). Among 992 children aged 25-59 months with a baseline SNA available, 90·1% (95% CI 86·1-92·9; 281/312) of those vaccinated using the DSJI had an immune response to type 2 compared with 93·8% (90·6-95·8; 331/353) of those vaccinated with N&S and 96·6% (94·0-98·0; 316/327) of those vaccinated with IDA. All (53/53) type 2 seronegative children seroconverted. For polio type 2, non-inferiority was shown for both the IDA (adjusted difference 0·7% [97·5% CI -3·3 to 4·7], unadjusted difference 2·9% [-0·9 to 6·8]) and DSJI (adjusted difference -3·3% [-8·3 to 1·5], unadjusted difference -3·7% [-8·7 to 1·1]) compared with N&S. Non-inferiority was shown for type 1 and 3 for the IDA and DSJI. Neither injection quality nor the training and experience of the vaccinators had an effect on immune response. No safety concerns were reported. INTERPRETATION: In a campaign, intradermal fIPV is safe and generates consistent immune responses that are not dependent on vaccinator experience or injection quality when administered using an N&S, DSJI, or IDA. Countries facing vaccine-derived poliovirus type 2 outbreaks should consider fIPV campaigns to boost population immunity and prevent cases of acute flaccid paralysis. FUNDING: World Health Organization and the Medical Research Council