Outcomes in patients with acute coronary syndrome in a referral hospital in sub-Saharan Africa

Abstract Background The incidence of acute coronary syndrome (ACS) is growing across sub-Saharan Africa and many healthcare systems are ill-equipped for this growing burden. Evidence suggests that healthcare providers may be underdiagnosing and undertreating ACS, leading to poor health outcomes. The goal of this study was to examine provider perspectives on barriers to ACS care in Tanzania in order to identify opportunities for interventions to improve care. Methods Semistructured in-depth interviews were conducted with physicians and clinical officers from emergency departments and outpatient departments in northern Tanzania. Thematic analysis was conducted using an iterative cycle of coding and consensus building. Results The 11 participants included six physicians and five clinical officers from health centers, community hospitals and one referral hospital. Providers identified barriers related to providers, systems and patients. Provider-related barriers included inadequate training regarding ACS and poor application of textbook-based knowledge. System-related barriers included lack of diagnostic equipment, unavailability of treatments, referral system delays, lack of data regarding disease burden, absence of locally relevant guidelines and cost of care. Patient-related barriers included inadequate ACS knowledge, inappropriate healthcare-seeking behavior and non-adherence. Conclusions This study identified actionable barriers to ACS care in northern Tanzania. Multifaceted interventions are urgently needed to improve care.

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Acute Coronary Syndromes in Sub‐Saharan Africa: A 10‐Year Systematic Review

Journal of the American Heart Association ◽

10.1161/jaha.120.021107 ◽

2021 ◽

Author(s):

Hermann Yao ◽

Arnaud Ekou ◽

Thierry Niamkey ◽

Sandra Hounhoui Gan ◽

Isabelle Kouamé ◽

...

Keyword(s):

South Africa ◽

Systematic Review ◽

Acute Coronary Syndrome ◽

Cote D'ivoire ◽

Côte D’Ivoire ◽

Sub Saharan Africa ◽

Cote D’Ivoire ◽

Coronary Syndrome ◽

Côte D'ivoire ◽

Sub Saharan

Background Data in the literature on acute coronary syndrome in sub‐Saharan Africa are scarce. Methods and Results We conducted a systematic review of the MEDLINE (PubMed) database of observational studies of acute coronary syndrome in sub‐Saharan Africa from January 1, 2010 to June 30, 2020. Acute coronary syndrome was defined according to current definitions. Abstracts and then the full texts of the selected articles were independently screened by 2 blinded investigators. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses standards. We identified 784 articles with our research strategy, and 27 were taken into account for the final analysis. Ten studies report a prevalence of acute coronary syndrome among patients admitted for cardiovascular disease ranging from 0.21% to 22.3%. Patients were younger, with a minimum age of 52 years in South Africa and Djibouti. There was a significant male predominance. Hypertension was the main risk factor (50%–55% of cases). Time to admission tended to be long, with the longest times in Tanzania (6.6 days) and Burkina Faso (4.3 days). Very few patients were admitted by medicalized transport, particularly in Côte d'Ivoire (only 34% including 8% by emergency medical service). The clinical presentation is dominated by ST–elevation sudden cardiac arrest. Percutaneous coronary intervention is not widely available but was performed in South Africa, Kenya, Côte d'Ivoire, Sudan, and Mauritania. Fibrinolysis was the most accessible means of revascularization, with streptokinase as the molecule of choice. Hospital mortality was highly variable between 1.2% and 24.5% depending on the study populations and the revascularization procedures performed. Mortality at follow‐up varied from 7.8% to 43.3%. Some studies identified factors predictive of mortality. Conclusions The significant disparities in our results underscore the need for a multicenter registry for acute coronary syndrome in sub‐Saharan Africa in order to develop consensus‐based strategies, propose and evaluate tailored interventions, and identify prognostic factors.

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Acute Coronary Syndrome in Patient with Viral Hepatitis C: An Underdiagnosed Condition in Sub-Saharan Africa

Cardiology and Cardiovascular Research ◽

10.11648/j.ccr.20190301.15 ◽

2019 ◽

Vol 3 (1) ◽

pp. 18

Author(s):

Helles Murielle Lema

Keyword(s):

Acute Coronary Syndrome ◽

Hepatitis C ◽

Viral Hepatitis ◽

Sub Saharan Africa ◽

Coronary Syndrome ◽

Viral Hepatitis C ◽

Sub Saharan

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Effect of a Triage‐Based Screening Protocol on Diagnosis and Treatment of Acute Coronary Syndrome in a Tanzanian Emergency Department: A Prospective Pre‐Post Study

Journal of the American Heart Association ◽

10.1161/jaha.120.016501 ◽

2020 ◽

Vol 9 (16) ◽

Author(s):

Julian T. Hertz ◽

Francis M. Sakita ◽

Godfrey L. Kweka ◽

Gerald S. Bloomfield ◽

John A. Bartlett ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Troponin I ◽

Point Of Care ◽

Sub Saharan Africa ◽

Shortness Of Breath ◽

Coronary Syndrome ◽

Screening Protocol ◽

Sub Saharan ◽

Research Assistants

Background Evidence suggests that acute coronary syndrome (ACS) is underdiagnosed in sub‐Saharan Africa. Triage‐based interventions have improved ACS diagnosis and management in high‐income settings but have not been evaluated in sub‐Saharan African emergency departments (EDs). Our objective was to estimate the effect of a triage‐based screening protocol on ACS diagnosis and care in a Tanzanian ED. Methods and Results All adults presenting to a Tanzanian ED with chest pain or shortness of breath were prospectively enrolled. Treatments and clinician‐documented diagnoses were observed and recorded. In the preintervention phase (August 2018 through January 2019), ACS testing and treatment were dictated by physician discretion, as per usual care. A triage‐based protocol was then introduced, and in the postintervention phase (January 2019 through October 2019), research assistants performed ECG and point‐of‐care troponin I testing on all patients with chest pain or shortness of breath upon ED arrival. Pre‐post analyses compared ACS care between phases. Of 1020 total participants (339 preintervention phase, 681 postintervention phase), mean (SD) age was 58.9 (19.4) years. Six (1.8%) preintervention participants were diagnosed with ACS, versus 83 (12.2%) postintervention participants (odds ratio [OR], 7.51; 95% CI, 3.52–19.7; P <0.001). Among all participants, 3 (0.9%) preintervention participants received aspirin, compared with 50 (7.3%) postintervention participants (OR, 8.45; 95% CI, 3.07–36.13; P <0.001). Conclusions Introduction of a triage‐based ACS screening protocol in a Tanzanian ED was associated with significant increases in ACS diagnoses and aspirin administration. Additional research is needed to determine the effect of ED‐based interventions on ACS care and clinical end points in sub‐Saharan Africa.

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Hypertensive crises in sub-Saharan Africa: Clinical profile and short-term outcome in the medical emergencies department of a national referral Hospital in Burkina Faso

Archives of Cardiovascular Diseases Supplements ◽

10.1016/j.acvdsp.2019.05.049 ◽

2019 ◽

Vol 11 (3) ◽

pp. e351

Author(s):

D.G. Mandi ◽

R.A. Yaméogo ◽

C. Sebgo ◽

J. Bamouni ◽

D.T. Naibé ◽

...

Keyword(s):

Burkina Faso ◽

Referral Hospital ◽

Sub Saharan Africa ◽

Short Term ◽

Term Outcome ◽

Short Term Outcome ◽

Medical Emergencies ◽

Sub Saharan ◽

Hypertensive Crises ◽

National Referral Hospital

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Effectiveness of preoperative bath using Chloroxylenol antiseptic soap on the incidence of post emergency Cesarean section surgical site infection at Mbarara Regional Referral hospital, Uganda: a Randomized Controlled trial

10.21203/rs.3.rs-16138/v1 ◽

2020 ◽

Author(s):

Henry Lukabwe ◽

Rogers Kajabwangu ◽

Dale Mugisha ◽

Horace Kizito ◽

Baraka Munyanderu ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Cesarean Section ◽

Controlled Trial ◽

Surgical Site Infections ◽

Referral Hospital ◽

Sub Saharan Africa ◽

Regional Referral Hospital ◽

Randomized Controlled ◽

Emergency Cesarean ◽

Sub Saharan

Abstract Introduction: Surgical Site Infections (SSIs) are infections that occur at or near the surgical incision within 30 days of the surgery. SSIs are the commonest form of hospital acquired infections in sub Saharan Africa with estimates between 15%-45%. Cesarean section (CS) is the single most important risk factor for postpartum infections, carrying a 5 to 20-fold increase in the risk of developing sepsis, with an even higher risk when the operation is an emergency. In sub Saharan Africa, the leading cause of maternal mortality is puerperal sepsis. There is a need for simple interventions that can reduce this burden of SSI in the limited resource settings. Therefore, the purpose of this study was to measure the effectiveness of chloroxylenol in reducing the incidence of post Cesarean section surgical site infections at Mbarara Regional Referral Hospital (MRRH).Methods: We conducted a single blinded randomized controlled trial at MRRH maternity ward in which women due for CS were randomized into either control or intervention arms. The intervention was a complete body bath with chloroxylenol antiseptic soap before the operation, while the control arm study participants received a standard pre-operative preparation procedures according to the existing ward protocol. All participants were followed up for 30 days and assessed using a standard SSI screening tool. Results: Ninety-six women were randomized, and 48 were assigned to either arm. The overall incidence of SSI was 30.21%. The incidence of SSI was significantly lower in the intervention compared to the control arm, at 6.25% in the intervention arm versus 54.17% in the control arm (p value<0.001). Chloroxylenol bath was protective of SSI with a 90% risk reduction for SSI (95% confidence interval of 67% – 97%). Conclusion: A preoperative bath with chloroxylenol for pregnant mothers is associated with a significantly lower risk of post Cesarean section surgical site infections. Health facilities with a high burden of post SSI should consider adding this simple and effective intervention to the existing infection prevention measures. Clinical Trials.gov registration (NCT03544710).

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Rates of refusal of clinical autopsies among HIV-positive decedents and an overview of autopsies in Uganda

Wellcome Open Research ◽

10.12688/wellcomeopenres.17316.1 ◽

2021 ◽

Vol 6 ◽

pp. 302

Author(s):

Olivie C. Namuju ◽

Richard Kwizera ◽

Robert Lukande ◽

Katelyn A. Pastick ◽

Jonee M. Taylor ◽

...

Keyword(s):

Family Satisfaction ◽

Referral Hospital ◽

Sub Saharan Africa ◽

Hiv Positive ◽

Next Of Kin ◽

Perceived Benefit ◽

Immunodeficiency Virus ◽

Sub Saharan ◽

Acceptance Rates ◽

National Referral Hospital

Background: Human immunodeficiency virus (HIV)-related mortality remains high in sub-Saharan Africa. Clinical autopsies can provide invaluable information to help ascertain the cause of death. We aimed to determine the rate and reasons for autopsy refusal amongst families of HIV-positive decedents in Uganda. Methods: We consented the next-of-kin for post-mortem examinations among Ugandan decedents with HIV from 2017-2020 at Kiruddu National Referral Hospital. For those who refused autopsies, reasons were recorded. Results: In this analysis, 165 decedents with HIV were included from three selected wards at Kiruddu National Referral Hospital. Autopsy was not performed in 45% of the deceased patients; the rate of autopsy refusal was 36%. The most common reasons for autopsy refusal were time constraints (30%), family satisfaction with clinical diagnosis (15%), fear of disfigurement of the remains (15%), and lack of perceived benefit (15%). By seeking consent from multiple family members and clearly explaining to them the purpose of performing the autopsy, we found a reduction in the rate of autopsy refusal among relatives of the deceased patients at this hospital compared to previous studies at the same site (36% vs. 60%). Conclusions: We found lower rates of autopsy refusal compared to previous studies at the same site. This underscores the importance of clearly explaining the purpose of autopsies as they increase active sensitization about their relevance and dispel myths related to autopsies among the general population. Good, culturally sensitive, and timely explanations to the family of the benefits of autopsy increase the rate of obtaining permission. Building capacity for performing autopsies by training more pathologists and increasing laboratory resources to decrease the turn-around-time for autopsy reports and extending these services to peripheral health facilities could improve autopsy acceptance rates.

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Understanding surgical care delivery in Sub-Saharan Africa: a cross-sectional analysis of surgical volume, operations, and financing at a tertiary referral hospital in rural Tanzania

Global Health Research and Policy ◽

10.1186/s41256-019-0122-2 ◽

2019 ◽

Vol 4 (1) ◽

Cited By ~ 1

Author(s):

Praveen Paul Rajaguru ◽

Mubashir Alavi Jusabani ◽

Honest Massawe ◽

Rogers Temu ◽

Neil Perry Sheth

Keyword(s):

Surgical Care ◽

Referral Hospital ◽

Sub Saharan Africa ◽

Surgical Volume ◽

Tertiary Referral ◽

Tertiary Referral Hospital ◽

Emergency Procedures ◽

Sub Saharan ◽

Improve Access ◽

Main Operating

Abstract Background Access to surgical care in Low- and Middle-Income Countries (LMICs) such as Tanzania is extremely limited. Northern Tanzania is served by a single tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC). The surgical volumes, workflow, and payment mechanisms in this region have not been characterized. Understanding these factors is critical in expanding access to healthcare. The authors sought to evaluate the operations and financing of the main operating theaters at KCMC in Sub-Saharan Africa. Methods The 2018 case volume and specialty distribution (general, orthopaedic, and gynecology) in the main operating theaters at KCMC was retrieved through retrospective review of operating report books. Detailed workflow (i.e. planned and cancelled cases, lengths of procedures, lengths of operating days) and financing data (patient payment methods) from the five KCMC operating theater logs were retrospectively reviewed for the available five-month period of March 2018 to July 2018. Descriptive statistics and statistical analysis were performed. Results In 2018, the main operating theaters at KCMC performed 3817 total procedures, with elective procedures (2385) outnumbering emergency procedures (1432). General surgery (1927) was the most operated specialty, followed by orthopaedics (1371) and gynecology (519). In the five-month subset analysis period, just 54.6% of planned operating days were fully completed. There were 238 cancellations (20.8% of planned operations). Time constraints (31.1%, 74 cases) was the largest reason; lack of patient payment accounted for as many cancellations as unavailable equipment (6.3%, 15 cases each). Financing for elective theater cases included insurance 45.5% (418 patients), and cash 48.4% (445 patients). Conclusion While surgical volume is high, there are non-physical inefficiencies in the system that can be addressed to reduce cancellations and improve capacity. Improving physical resources is not enough to improve access to care in this region, and likely in many LMIC settings. Patient financing and workflow will be critical considerations to truly improve access to surgical care.

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