The role of leadership in people-centred health systems: a sub-national study in The Gambia

Recently, increasing attention has been given to behavioural and relational aspects of the people who both define and shape health systems, placing them at the core. A growing refrain includes the assertion that important decisions determining health system performance, including agenda setting, policy formulation and policy implementation, are made by people. Within this actor-oriented approach, good leadership has been identified as a key contributing factor in health systems strengthening. However, leadership remains ill-defined and under-researched, especially in resource-limited settings, and understanding the links between leadership and health outcomes remains a challenge. We explore the concept and practice of healthcare leadership at sub-national level in a low-income country setting, using a people-centric research methodology. In June and July 2013, 15 in-depth interviews were conducted with key informants in formal healthcare leadership roles across urban, peri-urban and rural settings of The Gambia, West Africa. Participants included the entire spectrum of Regional Health Team (RHT) Directors and Chief Executive Officers of all government hospitals, as well as one clinical officer-in-charge in a secondary-level major health centre. We found reference to several important aspects of, and approaches to, leadership, including (i) setting a clear vision; (ii) engendering shared leadership; and (iii) paying attention to human relations in management. Participants described attending to constituencies in government, international development agencies and civil society, as well as to the populations they serve. By illuminating the multi-polar networks within which these leaders are embedded, and through which they operate, we provide insight into the complex ‘organizational ecology’ of the Gambian health system. There is a need to further research and develop healthcare leadership across all levels, within various political, socio-economic and cultural contexts, in order to better work with a range of health actors and to engage them in identifying and acting upon opportunities for health systems strengthening

Correspondence: Strengthening capacity, collaboration and quality of clinical research in Africa: EDCTP Networks of Excellence

Developing countries bear 90% of the global disease burden, but only access about 10% of globally available health research funding. Weak south–south networking hampers effective use of limited resources,production of critical mass of quality scientists, career opportunities and incentives to retain the few available scientists. The south must urgently act strategically to accelerate generation of talented scientists, createenabling environment and incentives to retain scientists and attract back those in diaspora. The creation of strong networks of excellence for clinical research among southern academic and research institutions is a novelstrategic approach championed by European and Developing Countries Clinical Trials Partnership to achieve the aforementioned goals and mitigate the high disease burden. It will promote strong collaboration, resource sharing and cross-mentorship allowing each partner to grow with complementary capacities that support each other rather than compete negatively. It will enable the south and Africa in particular to participate actively and own the means for solving its own health problems and raise the professional quality and capacity of southern institutions to forge better and equal partnership with northern institutions

Resting electrocardiographic and echocardiographic findings in an urban community in the Gambia

The presence of Left Ventricular Hypertrophy (LVH) in a patient with systemic hypertension deserves serious attention and makes its clinical diagnosis a priority. Over the years various criteriahave been proposed for the electrographic (ECG) diagnosis of LVH and the sensitivity and specificity of these criteria have been extensively studied in Caucasians. Recent evidence indicates that they areinapplicable to people of African descent. Unlike echocardiography (ECHO), the ECG is generally available, cheap but has a lower sensitivity in detecting LVH compared to echocardiography. Thisstudy was conducted to evaluate ECG criteria against 2-dimensional (2-D) guided M-mode echocardiography in the diagnosis of LVH in adult Gambians. Secondly, to determine the ECG criteria usingthe Minnesota, Araoye, Sokolow and Lyon or Wolff criteria with the overall best accuracy for the diagnosis of LVH. Two hundred and eight (208) consecutive patients with systemic hypertension (BP.140/90mmHg) with or without treatment and an age matched group of 108 non-hypertensive patients were enrolled from outpatient clinics. A questionnaire was filled. All patients were investigated with 2-D guided M-mode echocardiography and a standard 12-1ead ECG. Anthropometric measurements were also taken. The gold standard was the Penn formula to determine the left ventricular mass index (of 125 g/m2 in males and 110 g/m2 in females as the cut-off for LVH). Using this gold standard the prevalence of echocardiographic LVH was 47.5% and 27.8 % in the hypertensives and non-hypertensives respectively (P 0.05). Sokolow and Lyon criterion had overall best accuracy for the electrocardiographic diagnosis of left ventricular hypertrophyin hypertensives and is further recommended for use as such. But for non-hypertensives, the Wolff criterion had overall best accuracy

The HIV-1 protective-35SNP effect in Caucasians is CD8 T cell mediated

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Immunogenic Mycobacterium africanum Strains Associated with Ongoing Transmission in The Gambia

In West Africa, Mycobacterium tuberculosis strains co-circulate with M. africanum, and both pathogens cause pulmonary tuberculosis in humans. Given recent findings that M. tuberculosis T-cell epitopes are hyperconserved, we hypothesized that more immunogenic strains have increased capacity to spread within the human host population. We investigated the relationship between the composition of the mycobacterial population in The Gambia, as measured by spoligotype analysis, and the immunogenicity of these strains as measured by purified protein derivative-induced interferon-γ release in ELISPOT assays of peripheral blood mononuclear cells. We found a positive correlation between strains with superior spreading capacity and their relative immunogenicity. Although our observation is true for M. tuberculosis and M. africanum strains, the association was especially pronounced in 1 M. africanum sublineage, characterized by spoligotype shared international type 181, which is responsible for 20% of all tuberculosis cases in the region and therefore poses a major public health threat in The Gambia

False-negative RT-PCR for COVID-19 and a diagnostic risk score: a retrospective cohort study among patients admitted to hospital

OBJECTIVE: To describe the characteristics and outcomes of patients with a clinical diagnosis of COVID-19 and false-negative SARS-CoV-2 reverse transcription-PCR (RT-PCR), and develop and internally validate a diagnostic risk score to predict risk of COVID-19 (including RT-PCR-negative COVID-19) among medical admissions. DESIGN: Retrospective cohort study. SETTING: Two hospitals within an acute NHS Trust in London, UK. PARTICIPANTS: All patients admitted to medical wards between 2 March and 3 May 2020. OUTCOMES: Main outcomes were diagnosis of COVID-19, SARS-CoV-2 RT-PCR results, sensitivity of SARS-CoV-2 RT-PCR and mortality during hospital admission. For the diagnostic risk score, we report discrimination, calibration and diagnostic accuracy of the model and simplified risk score and internal validation. RESULTS: 4008 patients were admitted between 2 March and 3 May 2020. 1792 patients (44.8%) were diagnosed with COVID-19, of whom 1391 were SARS-CoV-2 RT-PCR positive and 283 had only negative RT-PCRs. Compared with a clinical reference standard, sensitivity of RT-PCR in hospital patients was 83.1% (95% CI 81.2%-84.8%). Broadly, patients with false-negative RT-PCR COVID-19 and those confirmed by positive PCR had similar demographic and clinical characteristics but lower risk of intensive care unit admission and lower in-hospital mortality (adjusted OR 0.41, 95% CI 0.27-0.61). A simple diagnostic risk score comprising of age, sex, ethnicity, cough, fever or shortness of breath, National Early Warning Score 2, C reactive protein and chest radiograph appearance had moderate discrimination (area under the receiver-operator curve 0.83, 95% CI 0.82 to 0.85), good calibration and was internally validated. CONCLUSION: RT-PCR-negative COVID-19 is common and is associated with lower mortality despite similar presentation. Diagnostic risk scores could potentially help triage patients requiring admission but need external validation

A comparison of tuberculous and bacterial native joint septic arthritis infections in a retrospective cohort: presentation characteristics, outcomes and long term follow up

Objectives This retrospective observational cohort study aimed to characterise and compare the demographics, initial laboratory tests and outcomes between patients with large-joint bacterial septic arthritis (BSA) and tuberculous septic arthritis (TBSA). Methods All patients with a culture from a large, native joint growing either non-mycobacterial bacteria or Mycobacterium tuberculosis between 1 January 2012 and 1 October 2018 in our institution were included. Clinical details and admission laboratory values were obtained from patient records. Comparisons were made by Mann-Whitney U, chi-squared tests, and logistic regression analysis. Results We identified 64 BSA and 29 TBSA. On average, the BSA cases were older, had higher CRP levels and neutrophil counts and lower albumin levels. The odds ratio for having a BSA was 46 in cases with a CRP greater than 100 mg/L (95% confidence interval (CI) 8.5–850, p < 0.001) and 24 with a neutrophil count greater than 7.5x109 (95% CI 6.1–160, p < 0.001). 51% of BSA were asymptomatic at last follow up compared to 72% of TBSA. 14% of the BSA cases died during admission; there were no deaths in the TBSA group. Conclusions Significant differences exist between patients with BSA and TBSA. Whilst no test is sufficient to exclude BSA, a raised neutrophil count or a CRP greater than 100 mg/L significantly increases the odds of a bacterial aetiology. Patients with BSA had worse long-term outcomes and higher incidence of inpatient mortality

Health Centre Surveys as a Potential Tool for Monitoring Malaria Epidemiology by Area and over Time

BACKGROUND: Presently, many malaria control programmes use health facility data to evaluate the impact of their interventions. Facility-based malaria data, although useful, have problems with completeness, validity and representativeness and reliance on routinely collected health facility data might undermine demonstration of the magnitude of the impact of the recent scaleups of malaria interventions. To determine whether carefully conducted health centre surveys can be reliable means of monitoring area specific malaria epidemiology, we have compared malaria specific indices obtained from surveys in health centres with indices obtained from cross-sectional surveys conducted in their catchment communities. METHODS: A series of age stratified, seasonal, cross-sectional surveys were conducted during the peak malaria transmission season in 2008 and during the following dry season in 2009 in six ecologically diverse areas in The Gambia. Participants were patients who attended the health centres plus a representative sample from the catchment villages of these health facilities. Parasitaemia, anaemia, attributable proportion of fever and anti-MSP1-(19) antibody seroprevalence were compared in the health facility attendees and community participants. RESULTS: A total of 16,230 subjects completed the study; approximately half participated in the health centre surveys and half in the wet season surveys. Data from both the health centre and community surveys showed that malaria endemicity in The Gambia is now low, heterogeneous and seasonal. In the wet season, parasitaemia, seroprevalence and fever prevalence were higher in subjects seen in the health centres than in the community surveys. Age patterns of parasitaemia, attributable proportions of fever and seroprevalence rates were similar in subjects who participated in the community and health centre surveys. CONCLUSION: Health centre surveys have potential as a surveillance tool for evaluating area specific malaria control activities and for monitoring changes in local malaria epidemiology over time

Highly Accurate Diagnosis of Pleural Tuberculosis by Immunological Analysis of the Pleural Effusion

Pleural TB is notoriously difficult to diagnose due to its paucibacillary nature yet it is the most common cause of pleural effusions in TB endemic countries such as The Gambia. We identified both cellular and soluble biomarkers in the pleural fluid that allowed highly accurate diagnosis of pleural TB compared to peripheral blood markers. Multi-plex cytokine analysis on unstimulated pleural fluid showed that IP-10 resulted in a positive likelihood ratio (LR) of 9.6 versus 2.8 for IFN-γ; a combination of IP-10, IL-6 and IL-10 resulted in an AUC of 0.96 and positive LR of 10. A striking finding was the significantly higher proportion of PPD-specific IFN-γ+TNF-α+ cell population (PPD-IGTA) in the pleural fluid compared to peripheral blood of TB subjects. Presence of this pleural PPD-IGTA population resulted in 95% correct classification of pleural TB disease with a sensitivity of 95% and specificity of 100%. These data suggest that analysis of the site of infection provides superior diagnostic accuracy compared to peripheral blood for pleural TB, likely due to the sequestration of effector cells at this acute stage of disease