Geneva Health Forum Archive

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GHF 2014 – PS01

Public Hospitals Can Innovate Too!
Prof. Louis Loutan
Former head of the division of International and Humanitarian Medicine at the Geneva University Hospitals
Prof. Didier Pittet
Head of the infection control unit and president of the commission on innovation at the Geneva university Hospitals
Prof. Brigitte Pittet
Chief of Division, Geneva University Hospitals, Switzerland
Prof. François Mach
Chief of Division, Geneva University Hospitals, Switzerland
Prof. Patrick Petignat
Chief of Division, Geneva University Hospitals, Switzerland
Ms. Anne Bourgeois
Physiotherapist, Geneva University Hospitals, Switzerland
Prof. François Chappuis
Chief of Division, Geneva University Hospitals, Switzerland
Dr. François Gilardoni
World Innovation Day, Innovation 4 Health, co-founder Special Advisor at Fongit Seed Invest, Switzerland
Public institutions often convey the image of being slow in responding to needs, plagued by inertia and leaving innovation to the private sector. This session will illustrate through numerous examples of projects implemented locally or abroad that innovation can be integrated in the overall strategy development of a public institution, such as a university hospital. It brings added value to the institution, strengthens its reputation, motivates its employees and retains them, it creates public value and a sense of satisfaction. Innovation can be built in at all levels of the institution and become a driving force. Partnerships with institutions abroad also play a significant role in developing and sharing new expertise, values and social responsibility.

Prof. Louis LoutanProf. Louis Loutan

Louis is the founder of the Geneva Health Forum and has been its President since 2006. In this capacity Louis is responsible for providing strategic guidance to the initiative and ensures that it continues to enjoy wide institutional support.

Louis is Head of the Division of International and Humanitarian Medicine in the Department of Community Medicine and Primary Care and a practicing clinician at the Geneva University Hospitals in Geneva, Switzerland. He also serves the University of Geneva as Associate Professor in International and Humanitarian Medicine.

Louis is a specialist in internal medicine and tropical medicine. Louis has extensive field experience in Africa, Asia, North America and Eastern Europe. Louis is the former president of the Swiss Society of Tropical Medicine and Parasitology; President of the International Society of Travel Medicine (2001-2003). He serves on the boards of public and academic organisations that are committed to advancing the cause of global access to health.

ProfPittet(2-Black)Prof. Didier Pittet

Didier Pittet, MD, MS, is the Hospital Epidemiologist and the Director of the Infection Control Programme at the University of Geneva Hospitals and Clinics (2500 beds), Geneva, Switzerland; Professor of Medicine and Hospital Epidemiology at the University of Geneva; and Attending Physician in Adult and Paediatric Infectious Diseases, University of Geneva Hospitals. He is also Visiting Professor, Division of Investigative Sciences and School of Medicine, Imperial College London, London, UK. Professor Pittet serves on the editorial boards of the American Journal of Infection Control, the American Journal of Respiratory and Critical Care Medecine, The Lancet Infectious Diseases and Infection Control and Hospital Epidemiology. He is also an editorial consultant of the Lancet. Professor Pittet currently leads the First Global Patient Safety Challenge “Clean Care is Safer Care” of the WHO World Alliance for Patient Safety. He was awarded the CBE in 2007 by Her Majesty Queen Elisabeth II for services to the prevention of healthcare-associated infection in the UK. Current major research interests include the epidemiology and prevention of nosocomial infections, methods for improving compliance with hand hygiene practices, and methods for improving the quality of patient care and patient safety.

PS01_Brigitte_PittetProf. Brigitte Pittet

Prof. Brigitte Pittet est médecin-cheffe du service de Chirurgie plastique, reconstructive et esthétique des Hôpitaux Universitaires de Genève. Ses principaux domaines d’intérêt sont la reconstruction craniofaciale et la reconstruction mammaire ainsi que les techniques de microchirurgie. Prof. Pittet organise régulièrement des missions humanitaires chirurgicales dédiées au traitement des séquelles de noma. Elle a reçu plusieurs distinctions pour ses activités de recherche axées sur la cicatrisation des plaies.

PS01_Patrick PetignatProf. Patrick Petignat

Prof. Petignat and his research group have experience in running clinical trials and epidemiological studies in the field of cervical cancer and HPV. They are also involved in the development of screening policy and colposcopy practice for the Groupement Romand de la Société Suisse de Gynécologie Obstétrique (GRSSO). They have recently developed and published consensus
guideline for cervical cancer screening and management of cervical dysplasia for the Swiss French Part (available at Patrick Petignat is a co-founder of the Swiss Working Group for
Colposcopy and Cervical Pathology and is member of the WHO Steering Committee on Comprehensive Cervical Cancer Control (C4-GEP).

chappuis_photo_3Prof. François Chappuis

François Chappuis is physician specialized in internal and tropical medicine. He completed a master in clinical tropical medicine at Mahidol University, Bangkok and a PhD in medical sciences at the University of Antwerp. He currently heads the division of tropical and humanitarian medicine of the Geneva University Hospitals and has been medical adviser for neglected tropical diseases at Médecins sans Frontières since 1999. His clinical research activities focus on African and American trypanosomiasis, leishmaniasis and snake bites.

PS01_Francois.Gilardoni.SmallPicMr. François Gilardoni

Francois Gilardoni is a venture capitalist, innovation expert and award-winning scientist educated in Switzerland and the USA with nearly two decades of international experience in the high-tech and financial industries.  Building on the success of the first Innovation Day (ID) held in Geneva in 2007, in 2012 he partnered with Professor Didier, ID founder and world renowned specialist in patient safety, to foster a global culture of innovation in Medical and Healthcare Science by promoting Innovation Days around the world.  In 2013, they launched the World Innovation Day (WID) and the World Innovation Academy (WIA) global initiatives. Francois holds a PhD (cum laude) in Computational Chemistry, as well as advanced degrees in Environmental Science and Computing.  He is the founder of Global Advisory Services (GlobAS), a boutique firm providing non-discretionary investment advisory services to clients seeking to expand their private equity portfolio in the high-tech industry and to ventures raising capital (debt or equity).

PS01_Anne_Bourgeois_HUG_squareMs. Anne Bourgeois

Anne Bourgeois graduated as a physiotherapist in Geneva. After some time in the private sector, she joined the Geneva University Hospitals in 2002, where she worked in various departments, in acute care and rehabilitation services. She has extensive experience in numerous humanitarian projects providing care and training local staff as trainers (South of Marocco 2002, Haiti 2010 with Handicap International (HI) and MSF, Yemen with ICRC 2012-2013). She currently is involved in a training in rehabilitation project in Haiti with HI.

PS01_Francois_Mach_006Prof. François Mach

Prof. François Mach has extensive experience in the field of Cardiology particularly, with respect to the development and progression of atherosclerosis diseases. After obtaining his MD at the University of Geneva, he studied Internal Medicine and Cardiology at Geneva University Hospital. Then, he moved for post-doctoral fellowship in the laboratory of Professor Peter Libby, Brigham and Women’s Hospital, Boston (1995-1999). After his return in 2000, he became full Professor of Cardiology and Head of Cardiology at the Geneva University Hospital. From 2012, he is President of the Swiss Society of Cardiology. François Mach is author of more than 250 publications with high Impact Factor and during his career he has already obtained more than 5 million euros as research grants, all funded by the European Community.

Prof. Mach is the director of the Cardiology Laboratory at School of Medicine of the University of Geneva that offers a number of general facilities.

His research group developed animal models of atherosclerosis, acute myocardial infarction, chronic myocardial ischemia and ischemic stroke. Several knockout mice on inflammatory genes are available in the Cardiovascular Center. In the last 10 years, the group of Prof Mach substantially contributed to better clarify the inflammatory mechanisms underlying atherosclerosis and its acute dramatic complications, such myocardial infarction and ischemic stroke in both human cohort and animal studies. In addition, he contributed to the design and achievement of several clinical research, multi-center studies, as well as establishment of several cohorts of CVD patients




GHF2014 – PS27 – Health as an Indicator of Sustainable Development: How Health Can Contribute to and Benefit from Sustainable Policies

Health as an Indicator of Sustainable Development: How Health Can Contribute to and Benefit from Sustainable Policies
Dr. Carlos Dora
Department of Public Health and Environment, World Health Organization, Switzerland
Prof. Ilona Kickbush
Director, Global Health Programme, The Graduate Institute of International and Development Studies, Switzerland
Health as an Indicator of Sustainable Development: How Health Can Contribute to and Benefit from Sustainable Policies
Ms. Natalie Mrak
Student, Masters of Development Studies, The Graduate Institute for International and Development Studies, Switzerland
Mr. Callum Brindley
Student, Masters of Development Studies, The Graduate Institute for International and Development Studies, Switzerland
Dr. Ralph Chapman, Environmental Studies Director, Victoria University, Wellington, New Zealand
Dr. Philippa Howden-Chapman, Professor of Public Health, University of Otago, and Director of the New Zealand Centre for Sustainable Cities, New Zealand
This session will begin with a comprehensive overview of the expansive literature, encompassing more than 20 years, on how health indicators can serve as measures of sustainable development and the presentation of a tool that has been developed which essentially combines all of this literature on indicators into one space. This will then set the stage for discussion on how this literature can essentially be placed into action. The session will entail perspectives from local, national and global levels as well as academic circles in order to provide a more comprehensive overview of the progress that has been made in incorporating health into sustainable development objectives as well as the challenges and the bottlenecks which still remain. The aim is to stimulate creative thinking and discussion around innovative ways through which health can become more embedded in the sustainable development agenda.This discussion is crucial particularly as the post-2015 development agenda talks continue. While the first set of Millennium Development Goals (MDGs) were a momentous endeavor to tackle crucial issues affecting the most vulnerable, they did not provide a comprehensive and integrated approach to tackling these challenges. Health was a dominant theme in the first set of MDGs, composing 3 of 8 goals but as 2015 approaches it is apparent that these goals do not comprehensively address the major health challenges of the 21st century for both developed and developing countries alike. While barriers to overcoming communicable diseases, maternal and child health still exist, issues such as tropical diseases (NTDs) and non-communicable diseases (NCDs) are posing challenges to existing approaches to health. A horizontal integrative approach is crucial to overcoming these new health challenges. For instance, good water and sanitation could prevent the infection from the majority of  NTDs while changes in daily routines, such as the substitution of motor transport for public or active transport, could reduce the incidence of NCDs.While recent literature has called for the inclusion of health in the post-2015 sustainable development agenda, there has not been a substantial discussion on how it could fit into this agenda and what exactly this health goal would look like as well as its feasibility at all levels of government from global to national to local.

Carlos Dora_squareDr. Carlos Dora

Carlos Dora, is a coordinator at the WHO HQ Public Health and Environment Department, leading work on health impacts of sector policies (energy, transport, housing and extractive industry), health impact assessment and co-benefits from green economy/climate change policies. He previously worked at the London School of Hygiene and Tropical Medicine (LSHTM), at the WHO Regional Office for Europe, at the World Bank, and with primary care systems in Brazil after practicing medicine. He serves in many science and policy committees, has an MSc and PhD from the LSHTM.  His publications cover health impact of sector and sustainable development policies, HIA and health risk communication.

Ilona KickbushProf. Ilona Kickbush

Ilona Kickbusch is the Director of the Global Health Programme at the Graduate Institute of International and Development Studies, Geneva. She advises organisations, government agencies and the private sector on policies and strategies to promote health at the national, European and international level. She has published widely and is a member of a number of advisory boards in both the academic and the health policy arena. She has received many awards and served as the Adelaide Thinker in Residence at the invitation of the Premier of South Australia. She has recently launched a think-tank initiative “Global Health Europe: A Platform for European Engagement in Global Health” and the “Consortium for Global Health Diplomacy”.

Her key areas of interest are global health governance, global health diplomacy, health in all policies, the health society and health literacy. She has had a distinguished career with the World Health Organization, at both the regional and global level, where she initiated the Ottawa Charter for Health Promotion and a range of “settings projects” including Healthy Cities. From 1998 – 2003 she joined Yale University as the head of the global health division, where she contributed to shaping the field of global health and headed a major Fulbright programme. She is a political scientist with a PhD from the University of Konstanz, Germany.

PS27_Natalie_MrakMs. Natalie Mrak

Natalie   Mrak is a Global  Health  Project Coordinator with the Access to Health (A2H) team. In  parallel, she is also pursuing a Master´s in Development Studies, with a concentration on Human, Financial and Economic Development, at the Graduate Institute for International and  Development Studies (IHEID).  At  the  Institute,  she  is  focusing  on  global health issues. including  health  and  sustainable  development  as  well  as  the role of emerging  economies  in  global  health  governance and diplomacy. While in Geneva,   Natalie   has   interned  for  Otsuka  Pharmaceuticals  in  their communications  division  and in the community mobilization unit at UNAIDS. Prior  to  her  arrival in Geneva, Natalie worked at UNICEF headquarters in New York for 4 years as the Executive Assistant to the Chief of the HIV and AIDS  programme. In addition, she has a Master´s in International Relations from  the  City College of the City University of New York (CCNY) where she focused  on  gender  and  development  issues  in  Eastern  Europe. Natalie received  her  Bachelor´s  degree  from Kenyon College where she received a dual degree in History, with honors distinction, and Spanish Studies as well as Magna Cum Laude and Phi Beta Kappa honors.

PS27_Callum_BrindleyMr. Callum Brindley

Callum Brindley is studying a Masters of Development Studies at the Graduate Institute for International and Development Studies in Geneva. He is also a part-time researcher with the Global Health Programme and has co-authored two WHO publications on Health in All Policies and health in the post-2015 development agenda. Prior to his post-graduate studies, Callum worked for three years with the Australian Agency for International Development.

Ralph Chapman (aug06) VUW photoDr. Ralph Chapman

Ralph directs the Graduate Programme in Environmental Studies at Victoria University. An environmental economist, he’s worked on energy, transport, urban design and climate change. He’s also worked with the New Zealand Ministry for the Environment, the NZ Treasury; the British Treasury in Whitehall; the OECD, in the Beehive, and as a negotiator for New Zealand of the Kyoto Protocol. Ralph has a first in engineering, a Masters in public policy, and a PhD in economics.

GHF2014 – PS17 – Antimicrobial Resistance: A Global Health Challenge. What Are the Integrated Solutions?

Antimicrobial Resistance: A Global Health Challenge.
What Are the Integrated Solutions?

Prof. Didier Pittet
Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
Dr. Benedetta Allegranzi
Service Delivery and safety department, WHO, Switzerland
Dr. Dominique Monnet
Senior Expert & Head of Programme, Antimicrobial Resistance & Healthcare-Associated Infections (ARHAI)
Office of the Chief Scientist,
European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
Dr. Benedikt Huttner
Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
Dr. Jean Pierre Bru
Hôpital de Annecy, France

Didier_Pittet_squareProf. Didier Pittet

Didier Pittet, MD, MS, is the Hospital Epidemiologist and the Director of the Infection Control Programme at the University of Geneva Hospitals and Clinics (2500 beds), Geneva, Switzerland; Professor of Medicine and Hospital Epidemiology at the University of Geneva; and Attending Physician in Adult and Paediatric Infectious Diseases, University of Geneva Hospitals. He is also Visiting Professor, Division of Investigative Sciences and School of Medicine, Imperial College London, London, UK. Professor Pittet serves on the editorial boards of the American Journal of Infection Control, the American Journal of Respiratory and Critical Care Medecine, The Lancet Infectious Diseases and Infection Control and Hospital Epidemiology. He is also an editorial consultant of the Lancet. Professor Pittet currently leads the First Global Patient Safety Challenge “Clean Care is Safer Care” of the WHO World Alliance for Patient Safety. He was awarded the CBE in 2007 by Her Majesty Queen Elisabeth II for services to the prevention of healthcare-associated infection in the UK. Current major research interests include the epidemiology and prevention of nosocomial infections, methods for improving compliance with hand hygiene practices, and methods for improving the quality of patient care and patient safety.

Allegranzi PhotoDr. Benedetta Allegranzi

Benedetta Allegranzi, MD, is a specialist in infectious diseases, tropical medicine, infection control and hospital epidemiology. She currently works at the World Health Organization (WHO) HQ (Service Delivery and Safety department), leading the “Clean Care is Safer Care” programme ( focused on hand hygiene, infection control and antimicrobial resistance in health care. Since 2013, Dr Allegranzi has gathered the title of full professor of infectious diseases in the official Italian professorship list and is adjunct professor of public health at the Faculty of Medicine, University of Geneva, Switzerland. She closely collaborates with the team at the Infection Control Programme and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals (Geneva, Switzerland), as well as with the Armstrong Institute for Patient Safety and Quality, John Hopkins University, (Baltimore, USA) for clinical research projects. She has experience in clinical management of infectious diseases and tropical medicine, and clinical research in healthcare settings in both developing and developed countries. She has thorough skills and experience in training and education.

She is the author or coauthor of more than 150 scientific publications, including articles published in high-profile medical journal such as the Lancet, Lancet Infectious Diseases, New England Journal of Medicine and the WHO Bulletin, and six book chapters.

Dominique_Monnet_squareDr. Dominique Monnet

Dr. Monnet received his degrees in pharmacy (PharmD) and clinical microbiology (PhD) from the University of Lyon, France, and then obtained further education as a hospital infection control specialist and epidemiologist.

Before joining ECDC in 2007, he worked in French hospitals, at the US Centers for Disease Control and Prevention (1993-1995) and at the Danish Statens Serum Institut (1997-2007) where he was coordinating surveillance of antimicrobial resistance and antimicrobial consumption in humans in Denmark.

His research interests include surveillance of antimicrobial resistance and antimicrobial consumption, the relationship between consumption of antimicrobials and resistance, and the factors that affect antimicrobial usage, both in hospitals and in primary care.

SONY DSCDr. Benedikt Huttner

Dr Benedikt Huttner is an infectious disease physician at the Infection Control Program of Geneva University Hospitals.

After medical studies in Munich (Germany) and Nice (France) he came to Switzerland in 2002 to train in internal medicine (Ticino) and infectious diseases (Zurich and Geneva). After a short stay in pediatrics he joined the infection control of Geneva University Hospitals (Prof. Didier Pittet) in 2007. Between 2010 and 2012 Benedikt was a research fellow at the division of epidemiology of the University of Utah (Prof. Matthew Samore) and the VA Salt Lake City Health Care System.  Benedikt’s research focuses on antibiotic stewardship and antimicrobial resistance, in the inpatient and outpatient setting. He is also an infectious disease consultant for the university’s geriatric hospital in Geneva.

Bru_squareDr. Jean Pierre Bru

MD, infectious diseases clinician, head of ID department at Annecy Hospital, a 1200 non-teaching French hospital.

Has experience in the management of infectious diseases, antimicrobial stewardship programs, and clinical research both in developing and developed countries.

Was expert in the field of antimicrobial treatments for twelve years at the French agency for medicine and health product safety.

Is editor in chief of ANTIBIOGARDE, a hospital digital guide that offer the particular feature to allow customization to serve as local frame of reference.

Dr Rifat Atun

RifatAtunDr Rifat Atun is Professor of Global Health Systems at Harvard University, where he is the Director of Global Health Systems Cluster at Harvard University's School of Public Health.

In 2006-13, Dr Atun was Professor of International Health Management and Head of the Health Management Group at Imperial College London. He is an Honorary Professor at the London School of Hygiene and Tropical Medicine. In 2008-12 he served as a member of the Executive Management Team of The Global Fund to Fight AIDS, Tuberculosis and Malaria as the Director of Strategy, Performance and Evaluation Cluster.

Rifat's research focuses on the design and implementation of health systems transformations and their impact on outcomes. His research also explores adoption and diffusion of innovations in health systems (e.g. health technologies, disease control programmes, and primary healthcare reforms), and innovative financing in global health. Organization. Rifat is a co-Investigator and the joint lead for the innovation work stream at the National Centre for Infection Prevention and Management at Imperial College. He is also a co-Investigator and the Theme Lead for 'Organisational Change, Sustainability and Evaluation' at Imperial College and Cambridge University Health Protection Research Unit for Antimicrobial Resistance and Healthcare Associated Infection. He has published widely in the Lancet, PLoS Medicine, Lancet Infectious Diseases, BMJ, AIDS, and Bulletin of the World Health Organization.

Rifat has worked with several governments globally and with the World Bank, World Health Organization, and the UK Department for International Development to design, implement and evaluate health system reform initiatives in more than 20 countries. He has led research and consultancy projects for GSK, Pfizer Inc., the Vodafone Group, Hofmann La Roche,  PA Consulting, and Tata Consulting Services.

Rifat was the Founding Director of the MSc in International Health Management, BSc in Management and Medical Science, and Founding Co-Director of the Masters in Public Health Programme at Imperial College. He has been a director of Imperial College spin out companies operating in areas of health technology.

Rifat is a member of the MRC Global Health Group as the MRC Infections and Immunity Board representative. He serves as  a member of the PEPFAR Scientific Advisory Board, the Norwegian Research Council's Global Health and Vaccination Research (GLOBVAC) Board, the Research Advisory Committee for the Public Health Foundation of India, and the US Institute of Medicine USAID Standing Committee on Strengthening Health Systems. In 2006-08 he served as a Member of the Advisory Committee for WHO Research Centre for Health Development in Japan. He was member of the Strategic Technical Advisory Group of the WHO for Tuberculosis and chaired the WHO Task Force on Health Systems and Tuberculosis Control. In 2009-12 he was the Chair of the STOP TB Partnership Coordinating Board.

Rifat is a Fellow of the Royal College of General Practitioners (UK), Fellow of the Faculty of Public Health of the Royal College of Physicians (UK), and a Fellow of the Royal College of Physicians (UK).

Detecting Malaria in Refugees living in Non-Endemic Area: South Africa

Author(s) Joyce Tsoka-Gwegweni1, Uchenna Okafor2.
Affiliation(s) 1Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa, 2Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Infectious Diseases
Summary The study presents findings from a research conducted in a refugee population in South African city known to be non-endemic to malaria transmission.
Background It is reported that 64% of malaria cases in South Africa are imported. This is expected given the high influx of refugees into the cities and reports by United Nations High Commission for Refugees that South Africa carries the highest number of asylum seekers globally. Although South Africa has planned to eliminate malaria by 2018, current interventions and research only take place in malaria endemic areas, which are remote and rural.
Objectives The aim of this study is to determine prevalence of malaria infection among a refugee population living in a malaria non-endemic city of KwaZulu-Natal province, South Africa.
Methodology After obtaining relevant approvals and consent, adult refugee participants were recruited from a faith-based facility offering social services in a city of KwaZulu-Natal province. The participants were screened for malaria using rapid diagnostic tests and confirmed with microscopy. Demographic data for the participants were obtained using a closed ended questionnaire.
Results Data were obtained for 303 participants consisting of 52% females and 48% males ranging from 19 to 64 years old. Of these 303 participants, 289 originated from different African countries, mainly central Africa. Two hundred and ninety participants provided a blood sample for screening of malaria. Of these, 3.8% tested positive for rapid diagnostic test and 5.2% for microscopy. The majority of malaria infections were due to Plasmodium falciparum.
Conclusion The study confirms important findings that include the prevalence of asymptomatic malaria infections detected in a refugee population and residing in an urban area of KwaZulu-Natal province that is not endemic for malaria. These findings have important implications for both public health and malaria control in South Africa, particularly since the country has decided to eliminate malaria by 2018. To achieve this goal, South Africa needs to expand research, surveillance and elimination activities to include non-endemic areas and marginalized communities. The findings further emphasize the importance of integrating services such as malaria surveillance into other public health intervention programmes, and provide refugees with full access to public health services. Other implications of the findings and possible challenges threating the success of the malaria elimination process and health service provision in South Africa are discussed.

Causes, determinants, andtrends in maternal mortality among Palestine refugees during 2000-2010

Author(s) Ali Khader1, Majed Hababeh2, Wafaa Zeidan3, Irshad Shaikh 4, Yousef Shahin 5, Akihiro Seita6, 7, 8
Affiliation(s) 1Health, UNRWA, Amman, Jordan, 2Health, UNRWA, Amman, Jordan, 3Health, UNRWA, Amman, Jordan, 4Health, UNRWA, Amman, Jordan, 5Health, UNRWA, Amman, Jordan, 6health, UNRWA, Amman, Jordan, 7, , , , 8, , ,
Country - ies of focus Palestine
Relevant to the conference tracks Women and Children
Summary Despite the hardship socioeconomic status, the patern of Maternal mortality among palestine refugee population is similar to that among stable midle income countries, A shift was observed during the last decade from causes related to poor obstetric care such as hemorrage and infection to thromboemblic diseases.
Background The United Nations Relief and Works Agency for Palestine Refugees in the Near East has for over 60 yearsprovided comprehensive primary health care to 5.2 million Palestine refugees in five fields of operation: Gaza, Jordan, Lebanon, Syria and the West Bank. Despite the contextual challenges of chronic instability and poverty, the agency maintains high standards of antenatal care supported with subsidy of delivery in local hospitals, with comprehensive follow up of all registered pregnant women.
During the period 2000-2010 a total of 978,446 pregnant women were registered and followed up through UNRWA antenatal care services. A system to trace the outcome of each pregnancy was established. During the first year (2000) of implementation, 2145 (2.8%) pregnancies were with unknown outcome that was reduced to only 199 (0.2%) cases in 2010 and during this period a total of 230 maternal deaths were reported.
Objectives The aim of this analysis is identify the main causes and determinents of maternal mortality among Palestine refugees women served by UNRWA PHC system
Methodology UNRWA uses the Confidential Maternal Mortality Enquiry method for in-depth investigation of the direct and indirect causes of each maternal death. This retrospective study examines 230 confidential enquiry reports on maternal deaths of Palestine refugee women in five fields of operation during one decade. The confidential enquiry is completed immediately after a maternal mortality. A thorough investigation is conducted by a special committee established to investigate and reoprt on each maternal mortality
Results Analysis of the confidential enquiry reports revealed a maternal mortality ratio of 24/100000 with significant variations among fields (Lebanon and Syria the highest at 34, followed by Gaza and West Bank at 25 and Jordan at 19). 1.8% delivered at home while 14.8% of deaths occurred at home. 53% of them died in hospitals during the intra-post-partum period. 88% received 4 or more antenatal visits. Maternal deaths increased with higher parity. There was a shift in the leading documented causes of maternal deaths from pre-eclampsia and hemorrhage to pulmonary embolism. Thromboembolism was the first cause of death with 41% followed by toxemia and hypertensive disorders at 12, heart diseases at 11.8%, hemorrhage at 10.5% and infection and sepsis at 7.4%
Conclusion Maternal Mortality has plateaued over the last 10 years among Palestine Refugees. We have managed to reduce the deaths from infections, hemorrhage and pregnancy induced hypertension but the deaths from obstetric embolism and medical disorders in pregnancy have either stayed the same or have increased over the years. This can be partially attributed the lack of embolism prophylaxis in high risk cases as well as poor care of high risk women with medical disorders prior to pregnancy

Risk Factors and Practices contributing to Newborn Sepsis in Buyende District, Uganda.

Author(s) John Bua1, David Mukanga2, Elizabeth Nabiwemba3
Affiliation(s) 1Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 2Bill & Melinda Gates Foundation, Bill & Melinda Gates Foundation, Kampala, Uganda, 3Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda.
Country - ies of focus Uganda
Relevant to the conference tracks Women and Children
Summary This was a facility based cross sectional study in Kidera sub-county, Buyende district, Uganda. It aimed at identifying potential risk factors and describing practices contributing to newborn sepsis in Buyende district in order to make recommendations that will influence behaviour change at community level. 174 newborns participated. 21.8% were laboratory confirmed to have sepsis. The main causative agent was staphylococcus aureus (31.6%). Risk factors included inappropriate cord care (77.6%) and not practicing routine hand washing (78.2%). Therefore health education messages should target importance of hand washing and cord care for newborns in the communities.
Background In Uganda, it’s estimated that newborn deaths contribute to over 38% of all infant deaths (92,000 in 2010). Despite different mitigation interventions over years, the newborn mortality rate is high at 27/1000 and newborn sepsis contributes to 31% of mortality in Uganda. Therefore, improved strategies that will contribute to the reduction of newborn sepsis need to be developed. However we need to understand the actual practices and risks present that contribute to new cases of sepsis. These need to be put in context, for without reliable evidence it’s difficult to know whether proposed interventions will work.
Objectives To identify potential risk factors and describe practices contributing to newborn sepsis in Buyende district so that recommendations can be made that will influence behaviour change at community level.
The specific study objectives were;
 To assess the prevalence of risk factors for newborn sepsis in Kidera County, Buyende district.
 To describe practices contributing to newborn sepsis within the health facilities.
 To describe practices of mothers or caregivers of newborn contributing to newborn sepsis.
Methodology The study was conducted at Kidera Health Centre, a level IV facility located in Kidera County, Buyende District Eastern Uganda. Kidera health centre is the highest and main referral unit for Buyende District. Kidera Health Centre serves the 5 counties in the district with an estimated population of 248,000 people.This was a health facility based cross sectional study in Kidera sub county, Buyende district. Mothers or care takers of sick newborns and health workers were interviewed. The dependent variable was a newborn having laboratory confirmed sepsis. Independent variables include; social demographics, mother’s ANC, delivery and PNC history, birth weight, gestation age and newborn care practices. Semi-structured questionnaires and Key informant guides were used to collect quantitative and qualitative data.
Results 174 mothers and 174 newborns participated in the study. The majority of the mothers (73%) were peasant farmers. Few of the mothers had attained an education level above primary school (33.9%). The age range for the mothers was from 16 to 44 years (mean: 26.3 years).21.8% of the admitted newborns with signs and symptoms for sepsis were laboratory confirmed. The identified causative agents included; staphylococcus aureus (31.6%), Neisseria meningitides (21.%), streptococcus pyogenes (10.5%) and Haemophilus influenza (5.3%). The causative agents were found to be resistant to some of the commonly used drugs that included; penicillin, chloramphenicol, cloxacillin and gentamycin.Prevalent risk factors included delivery outside the health facility (43.1%), inappropriate cord care (77.6%), care givers not practicing hand washing before handling the newborn (78.2%) and lack of knowledge about newborn care (39.7%).The interview of key informants revealed that the health facility didn’t have resources to offer routine screening for bacterial infections among pregnant women during ANC visits. The available resources were for vertical programs targeting only HIV and malaria. The health facility also had no equipment or a special room were sick newborns in critical condition could be managed appropriately. The other health system challenges identified included lack of antibiotic syrups for treating newborns and inadequate supply of laboratory reagents to investigate causes of ill health in newborns.

Since the study was facility based some sick newborn cases that weren’t brought to the health unit for care could have been missed. However, community health workers in areas served by the health facility were encouraged to refer all cases of sick newborns for care.

Conclusion Most common aetiological agent for newborn sepsis was Staphylococcus aureus followed by Neisseria meningitides. The practice of not routinely washing hands before touching the newborn and inappropriate cord care were leading factors contributing to spread of infection to newborns in the community. Therefore all pregnant women and women in postnatal positions need to be health educated about the importance of hygienic cord care and washing hands before touching the newborn. The health education can be given to mothers attending antenatal, delivery or postnatal at the facility by the health workers. Community health workers, where they exist, can be used to educate mothers in the community about proper newborn care and how to prevent spread of sepsis.

Modelling potential distribution of current and future malaria in Tanzania: An Ecological Niche framework

Author(s) Benjamin Mayala1, Leonard Mboera2, Edwin Michael3
Affiliation(s) 1Disease Surveillance and GIS, National INstitute for Medical Research, Dar es Salaam , Tanzania, 2ICT, NIMR, Dar es Salaam, Tanzania, 3Department of Biological Sciences, University of Notre Dame, Notre Dame, United States.
Country - ies of focus Tanzania
Relevant to the conference tracks Innovation and Technologies
Summary Malaria is endemic in most parts of Tanzania and remains a major cause of morbidity and mortality both in rural and urban areas. Ecological niche modelling (ENM) has been considered a useful tool to assess the potential geographical distribution of various species. The application of such tool is very limited in predicting the potential distribution of diseases, especially when using occurrence (presence). In this study an ensemble model approach was employed to predict the current and future (2050) potential distribution of malaria in Tanzania. The ensemble approach demonstrated an enhanced prediction model compared to the individual model outputs.
Background Malaria is a leading cause of morbidity and mortality accounting for over 30% of the disease burden in Tanzania. Over 95% of the 37.4 million people in the country are at risk of malaria infection. Various factors account for malaria in Tanzania, which include demographic factors, socioeconomic factors, weak health systems, a limited budget, poor governance and accountability, antimalarial drug and insecticide resistance, environmental and climate change, vector migration, and land use patterns. Efforts have been employed to reduce malaria in Tanzania, which include insecticide treated mosquito nets, indoor residual spraying, improved diagnosis by microscopy and rapid diagnostic tests, effective treatment of cases, and implementation of intermittent presumptive treatment of pregnant women. In spite of the many efforts to combat malaria, the disease remains a leading public health problem in most parts of the country. Climate conditions such as precipitation, temperature, and relative humidity have a substantial impact on malaria. Despite the importance of these factors to the distribution of malaria, limited studies have been undertaken to address the association between climatic conditions and malaria epidemics.
Objectives Previous attempts to map the geographical distribution of malaria have focused on a theoretical model that is based on available long-term climate data, as well as empirical models that fit malaria data to environmental factors to predict the number of months during which transmission is possible. These studies have not demonstrated the predictive ability beyond the input data area. Ecological niche modelling (ENM) has been considered a useful tool to assess the potential geographical distribution of species. It has been applied to diseases to assess the potential distribution of vectors. Applications of ENM to study the distribution of malaria using occurrence cases are limited in Tanzania. Here, we adapt modelling techniques, to predict the current and future potential distribution of malaria. The goals of the study were to (i) identify possible distribution areas of malaria using an ensemble approach that integrate multiple individual models to generate a better and more conservative overall solution, (ii) identify the environmental and climate conditions correlated with malaria occurrences, estimate the population at risk, and (iii) determine how future climate change may affect the distribution of malaria in Tanzania.
Methodology Data: Malaria occurrence point data were obtained from the Ministry of Health and Social Welfare. These are reported cases from various health facilities in the country. The Current and future (2050) environmental data used in our study were obtained from CliMond gridded climate data, which represents an improvement on the existing global climate data available for bioclimatic modelling. Thirteen environmental variables were used from CliMond; this included eight bioclimatic variables, monthly minimum and maximum temperatures, monthly precipitation, monthly altitude and relative humidity. The 8-bioclimatic variables were mean temperature of wettest quarter, mean temperature of driest quarter, mean temperature of warmest quarter, mean temperature of coldest quarter, precipitation of wettest quarter, precipitation of driest quarter, precipitation of warmest quarter, and precipitation of coldest quarter. The study also included other variables such as human population density and normalised difference vegetation index (NDVI). To avoid fitting the model into too many environmental variables, we extracted the environmental information from each presence data and performed a Pearson correlation tests to see if any of the layers were too similar to include in a model together.
Data Processing: The environmental data used for model development were imported into ArcGIS 10.1 software in which they were re-projected to the same coordinate system, clipped to an area encompassing the administrative boundaries of Tanzania, resampled to obtain the same pixel resolution of 5km, extracted to obtain same dimensions, and converted to ASCII format.
Models development: We considered eight modeling algorithms for the ENM development, GAM, GLM, GBM, MAXENT, MARS and RF were implemented in biomod2 package in Revolution R software, SVM using dismo package and GARP using a Desktop GARP.
Ensemble Model Prediction: An ensemble approach was adapted in our study by combining the eight model output through a weighted average using two thresholds (i) the 5th percentile of the training presence (5% TP) and (ii) the least training presence (LTP).
To estimate the populations at risk of malaria, we reclassified the ensemble model outputs to binary maps (which have pixel values of 0 - no malaria and 1 - malaria present) using the two thresholds - 5% TP and LPT. ArcGIS tools were used to compute the population and districts predicted at risk to malaria
Results The overall contribution of each environmental variable to all the models ranged from 2% to 62%. Population density was the main variables influencing the potential distribution of malaria in all the models. Relative humidity contributed 10.5% to the model followed by altitude (10%) and precipitation of driest quarter (5.4%). The other variables had less influence. The prediction maps revealed that almost the whole country is endemic for malaria. However, the probability of malaria presence varies spatially. All the models depicted high probability (0.5 or greater) of occurrence of malaria in the east and south coast of Indian Ocean, north regions and along Lake Victoria. The models depicted a medium probability of malaria occurrence along the central and west regions. The ensemble model at 5% TP threshold demonstrated high occurrence of malaria in the east, coast of Indian Ocean, north regions and along Lake Victoria, a pattern from east to central, then low occurrence from central to west and also south parts of the country
The ensemble model future (2050) prediction at 5% TP threshold showed an increase/shift of malaria occurrence in the northern part and towards the central part of the country is expected. High percentage of malaria occurrence is predicted in the southern highlands and southern regions of the country. Some areas are predicted with low percentage occurrence in the central regions and areas in the west of the country. Areas in the north, around Lake Victoria and along the coast of Indian Ocean are predicted to maintain the highest percentage of malaria occurrence.
The current population at risk of malaria is estimated to be 29 and 34 million, and this could rise in the future to 81.58 and 93.7 million. About 79% of the districts are at high risk for malaria, which is predicted to increase to 84% in future
Conclusion A link between climate change and malaria has been described previously; particularly temperature and rainfall are mentioned as the major variables contributing to malaria distribution. The present study, however, shows a lesser contribution of temperature and rainfall in the development of the models, as compared to population density, which depicted the highest contribution. This suggest that (i) population density is the key variable in malaria and (ii) malaria cannot necessary be caused by climate variables, as they may exhibit a smaller role in determining the ecological niche and hence the potential distribution of malaria. However, despite the potential influence of the population variable shown in our model outputs, it is then clear that population density, environmental variables and other factors (than those we used) will need to be included in studies attempting to model malaria endemicity.
Our findings showed high percentage areas predicted by the ensemble for both current and future - 2050, whereas individual models resulted into low predicted areas. The results suggest that ensemble model predictions are more robust than the predictions from individual models.
An important implication of our model is that the predicted distribution of malaria in the various districts in Tanzania can inform the selection of locally appropriate control interventions. The malaria control program can plan better for the distribution of resources by specifically focusing on the areas predicted to be at high risk.

Using Technology and Community Empowerment to Treat Tuberculosis.

Author(s) Shelly Batra1.
Affiliation(s) 1Senior Management, Operation ASHA, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Infectious Diseases
Summary TB is has been declared a health emergency by WHO. Over 9 million people are newly infected with TB and 1.4 million die annually. Incomplete TB treatment has led to an alarming rise in DR-TB (Drug Resistant TB), a man-made epidemic. MDR-TB (Multi Drug-Resistant TB), if not fully treated, leads to the dreaded XDR-TB (Extremely Drug-Resistant TB), causing greater suffering and economic loss. Operation ASHA’s innovative idea is a combination of our comprehensive model and high leverage of low-cost biometric technology, eCompliance. We monitor every dose taken by MDR-TB patients to prevent XDR, because MDR-TB treatment is often left incomplete due to long duration and debilitating side effects.
What challenges does your project address and why is it of importance? TB is an airborne infectious disease, which transcends all socio-economic, cultural and physical barriers. India carries 26% of the worldwide TB burden. Patients are extremely poor, malnourished, living in cramped, ill-ventilated homes. Poor quality coal for cooking creates smoke, choking the lungs, thus making them susceptible to TB. They live on less than $1.25 a day (World Bank) and cannot afford to lose work and wages to access TB care. Although Government provides free diagnostics & medicines, treatment centres are few and far between. Patients find it impossible to adhere to the regimen, which requires 60 centres-visits over 6 months. Even if they start treatment, once they feel better they tend to stop for fear of losing jobs or of discrimination. This leads to various DR-TB strains, which are near to impossible to treat. Each patient infects 10-15 others, increasing the number of DR-TB cases exponentially. Social stigma, fear and misconceptions all explain poor adherence. Out of 600,000 MDR-TB patients globally, 100,000 are in India. XDR-TB is rampant. Mumbai recently reported 12 cases of TDR-TB (Totally Drug-Resistant TB), which has no treatment. DR-TB is serious socio-economic issue causing tremendous economic loss. Thus, treating MDR-TB fully will prevent XDR & TDR-TB.
How have you addressed these challenges? Do you see a solution? Operation ASHA’ (OpASHA) model and eCompliance effectively tackle lingering problems in TB treatment: patient identity fraud, missed doses, data fudging and high treatment cost. OpASHA fosters community empowerment and employs TB treatment providers who are locals from the communities we serve. With their knowledge of the local language and geography it is far easier for the treatment to reach disadvantaged people. Providers gain the community’s trust and help destigmatise TB through comprehensive education. They assure no patient loses their job or is ostracised by their family. We effectively utilise religious and social leaders to ensure patients adhere to their regimen. OpASHA establishes DOT (Directly Observed Treatment) centres within disadvantaged communities that are accessible and open at convenient times so no patient has to miss work and wages. One DOTS centre serves a population within 1.5km radius. To ensure each dose is taken we use eCompliance, which has a fingerprint reader attached to a netbook computer (or android phone). To register in our centre, new patients must provide fingerprints. Afterwards, every time they come for their free TB treatment they provide fingerprints to verify their identity. To decrease missed doses we rely on our providers and eCompliance for follow up. If a patient misses a dose, eCompliance sends an SMS immediately to the Programme Manager & Treatment Provider. Providers must follow up within 48hrs, find the patient, repeat TB education, administer TB medicine and obtain a fingerprint as proof of visit. If patients experience side-effects, providers either treat them or, if severe, refer them to the hospital.eCompliance eliminates data fudging because we use fingerprints for registering patients, rather than rely on manual data entry. The back end EMR (Electronic Medical Record) generates a set of 100% accurate reports, which previously was a time consuming task as our staff did it manually and with errors. eCompliance saves 30% of provider’s time which is now spent on valuable Active Case Finding and Patient Counselling.We recently upgraded eCompliance to follow MDR-TB treatment, thus preventing XDR-TB. We are also installing eCompliance on android phones. This substantially reduced our terminal costs by 40% and the cost of treatment per patient to less than $3. LGT Venture Philanthropy found that “OpASHA’s cost for treating each patient in India is approximately 19 times lower than the nearest other provider."
How do you know whether you have made a difference? OpASHA believes in a measurable impact, thus generating far more detailed reports than the Government. The following shows our achievement thus far:• We serve 6.1 million disadvantaged people in India and Cambodia
• 31,150+ TB patients treated in more than 3,000 rural areas and urban slums
• We have successfully reduced default rates from as high as 36% to as low as 1.5 %, thus minimising the risk of MDR-
• Treating over 70 MDR patients; supporting 2 XDR patients and one TDR patient with medicines and protein supplements.
• Distributed 570,000 painkillers, 780,000 antacid tablets, 315,000 antiemetic tablets, 240,000 iron tablets, 45,000 calcium tablets, 30,000 condoms, 12,000 sachets of Oral Rehydration Salt, 3,500 packets of protein supplements, 5 tons of food and 4000 blankets.
• 24 Female TB patients were provided vocational training to prevent them from being abandoned by families.
• $150/year increased income through reinstated productivity from TB, equivalent to an annuity of $1,877; treated patients have benefited by $56 million, $13,150 saved by economy for each person treated (Annual TB Report 2011: Govt. of India).
• 190 disadvantaged persons provided dignified sustainable full-time work.
• Income of 178 micro-entrepreneurs in disadvantaged localities (Community Partners) enhanced substantially.
• Social return on investment (SROI) of 3217% i.e. for every dollar invested, the society and the economy benefit by $49.3.Apart from the above, we also regularly measure, collate and analyse the following parameters
• User satisfaction metrics
• Access/ utilisation metrics: Detection as a percentage of prevalence; target is 100%
• Cost and sustainability metrics: Monthly expenses, Cost per patient & Cost per
Treatment / DOTS centre
• Achievement of positive health outcomes: Increase in body weight during the treatment.OpASHA has partnered with J-PAL, MIT in USA, which has conducted an RCT (randomised control trial) to assess the impact of OpASHA’s incentive-based salaries. We have received funding from USAID for the second RCT to assess the benefit of eCompliance. This is helping impact policy in India and abroad.
Have you or the project mobilized others and if so, who, why and how? The overarching principle of OpASHA is providing free, quality TB treatment to the doorsteps of the disadvantaged, while at the same time mobilising them to take self-initiative to improve their health as well as their socio-economic lifestyle. We believe OpASHA’s localised model is an efficient way of generating that mobilisation. For instance, in Cambodia all of our employees are locals, except for the Country Director. 80% of our budget is used to generate jobs for the disadvantaged in India and Cambodia. Within 6 years OpASHA became the 3rd largest TB treatment provider worldwide & the biggest in India by using a high-impact/low-cost, scalable & replicable model. In 2012 The Millennium Villages Project & Columbia University replicated our model and eCompliance in Uganda with “staggering improvement” in results. It took only 8 hours of Skype calls to train the master trainer in Uganda, who then trained their local providers. All technology, training and troubleshooting was done remotely from our office in India. Columbia University is now replicating eCompliance in the Dominican Republic.TB is not only a serious medical issue but it also has serious gender-related consequences. In India 100,000 female TB patients are thrown out of their homes each year by their families, left to die of disease and starvation. 300,000 children have to leave school because of TB either as a result of the infection, or because the parents have TB, in which case the child has to work to support the family (Government of India). OpASHA regularly employs women as TB treatment providers, thus reducing gender disparity. In return, not only do they generate income to support their families but they also gain great respect from the communities who treat them as doctors. In addition, at the end of each quarterly report we reward the provider with the most successful rate of active TB case finding.OpASHA’s delivery of effective TB treatment to women and girls, and in general to the “poorest of the poor”, remote and marginalised tribal communities in India, alleviate the adverse medical, social, economic and gender-based effects of TB, both on the individuals and their communities. This will, in turn, improve productivity, raise income, prevent economic loss, provide skills, training and employment for semi-literate providers in those communities, and enable access to services for the deeply marginalised tribes.
When your donor funding runs out how will your idea continue to live? OpASHA’s collaboration with the Indian Government increased our leverage by more than 4 times. They provide us with free TB and MDR-TB diagnostics, physician consultations and medicines for the communities we serve. The government also gives a grant per patient, which we receive 2 years after starting patient’s treatment. At the moment the government grant covers our entire field costs, i.e. cost of operations, thus our fieldwork is sustainable. Nevertheless, the grant still comes 2 years late. This means that in the meantime we need donor funds to help establish and operate those same centres for 2 years, as well as cover administrative expenses. This makes the government grant currently inadequate. As the eradication of TB is one of the Millennium Development Goals and due to rapid proliferation of DR-TB cases, the Indian government is focused more than ever on TB eradication, which has become a priority for politicians and policy makers. Hence, the Government has declared a plan to increase funds for TB treatment by at least 4 times and also to keep pace with the inflation by steadily increasing the funds. It has been decided that the money will also be given upfront to NGOs rather than being delayed for 2 years. Because of that we can use this grant to establish and operate our centres and continue treating patients year after year. Once the new plans come into place our entire programme will truly become self-sustaining and we will no longer be dependent on donor funds at all.The eCompliance initiative comes at a cost of $3 per patient, which is more than offset by increased productivity of our providers and office staff so it does not add to the per patient cost. eCompliance is therefore, self-sustaining from the very beginning.

Would you Terminate a Pregnancy Affected by Sickle Cell Disease? Views of Doctors, Parents and Patients in Cameroon.

Author(s) Ambroise Wonkam1, Jantina de Vries2, Charmaine Royal3, Dora MBanya 4, Jeanne Ngongang 5, Fru Angrafo III6
Affiliation(s) 1Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, 2Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, Institute for Genome Sciences & Policy, Duke University, Durham, United States, 4Department of Medicine, Faculty University of Yaoundé I, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon, Biochemestry, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon, Surgery, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.
Country - ies of focus Cameroon
Relevant to the conference tracks Women and Children
Summary We studied the views of 110 doctors, 130 parents with one living child with SCD (Sickle Cell Disease), and 89 adults patients suffering from SCD, regarding prenatal genetic diagnosis and termination of a SCD-affected pregnancy.
The majority accepted the principle of prenatal genetic diagnosis for SCD (78.7%, 89.8% and 89.2%). The majority of parents accepted the principle of termination of SCD-affected pregnancy (62.5%) as opposed to doctors and patients where this group were in the minority (36.1%, and 40.9 %). Parents and patients who rejected termination of pregnancies claimed ethical reasons (69.1 and 78.1%) while those who accepted it feared having another SCD-affected child (98.1 and 88.9%) with a poor quality of life (92.6% and 81.5%).
Background Patients with Sickle Cell Disease (SCD) can suffer from anemia, painful episodes, susceptibility to infection, stroke, and chronic organ damage (kidneys, lungs, heart, brain). There is currently no cure available for SCD, but the condition can be managed using a variety of therapies. When the condition is not managed patients tend to die in early childhood as occurs in many African countries.
In Cameroon it is possible to test for sickle cell homozygosity before birth, and in fact Prenatal Genetic Diagnosis (PND) represents one type of preventive strategy, as it is offered as a reproductive option to at-risk parents. PND provides parents with a reproductive option to test at-risk pregnancies and make decisions regarding medical abortion.
However, legal bans on abortion exist in virtually all African countries and when allowed medical abortion is often restricted to direct threats to maternal health. This raises important ethical questions regarding the desirability of terminating affected pregnancies.
Many parents currently caring for a child with SCD opt to abort a fetus that is also suffering from SCD. What has not yet been investigated is the comparative views of parents to those of health care providers and patients living with SCD.
Objectives We examined the attitudes of a sample of Cameroonian medical doctors, parents with at least one SCD-affected child, adult SCD patients towards PND and TAP. There were two major research questions: (1) their agreement with prenatal genetic diagnosis and pregnancy termination in general (2) their agreement with prenatal genetic diagnosis for SCD, and pregnancy termination for SCD, and the reasons for their attitudes.
Methodology Design
This research was a quantitative social science study administered by structured questionnaires.
Sample Population and Eligibility Criteria.
The sampling methods used included both purposeful and convenience sampling.
Medical doctors were recruited from a National Medical Conference for continue medical education. In an attempt to ensure inclusion of parents and adult SCD-affected patients and incorporate the entire spectrum of this illness, we issued a call for participation using the national Cameroonian media. We also approached two SCD Patients’ Associations in Cameroon. Participants needed to be at least 18 years old with a diagnosis of SCD that was confirmed by a laboratory documentation of their hemoglobin electrophoresis.
Questionnaire Format.
The data were collected by means of a structured questionnaire consisting of three sections of closed-ended questions. These were (1) Socio-demographic characteristics; (2) Attitudes towards SCD screening policies; and (3) Attitudes about principles of SCD- prenatal diagnosis and termination of an affected pregnancy if the participant’s unborn child were proven to be affected. Response options were “Yes,” “No” or “Undecided”.
Research Setting and Data Collection.
The study was conducted at the Yaoundé Central Hospital where face-to-face questionnaires interviews were conducted. Informed consent was also obtained at this stage. In addition to the introductory explanation, each patient was given full non-directive genetic counseling with neutral information concerning PND and its reproductive options. Images were used to explain the obstetric procedure of PND and risks (specifically 1% induced miscarriages). Information on the available therapeutic options and follow up for patients with SCD was reviewed and the participants were given an opportunity to ask questions. The information provided during this counseling session was equivalent to the information that prospective parents would have received had they been seeking PND for SCD.
Data Analysis.
Data were analyzed using SPSS (Statistical Package for Social Sciences, Chicago). A comparison between two or more variables was evaluated by non-parametric tests (H test of Kruskal-Wallis or Z test of Kolmogorov-Smirnov, when applicable). The p values were considered significant if they reached 95%.
Results The majority of parents participants lived in urban areas (89%), were female (80%), Christian (93%), married (60.2%) in monogamous households (81.1%), were employed (61.7%), and had at least a secondary or tertiary education (82%). Similarly, the majority of the patient participants were urban dwellers (84.3%), female (57.3%), Christian (95.5%), single (90.9%), with a secondary/tertiary education (79.5%).
The clinical profile of participant children and patient participants indicated that they suffered from (relatively) severe forms of SCD. The majority of research participants received poor treatment for their SCD. Only 4.4% of participants received hydroxyurea treatment, the only treatment currently available to manage SCD. Nearly 90% (89.7%) had received traditional medicine for their conditions on at least one occasion in the past.
The majority accepted the principle of prenatal genetic diagnosis for SCD (doctors: 78.7%; parents: 89.8% and patients: 89.2%). The majority of parents accepted the principle of termination of SCD-affected pregnancy (62.5%), but doctors and adults patients were less comfortable with this principle (36.1%, and 40.9 % acceptance, respectively). The acceptance of the principle of medical termination for SCD increased with unemployment status. (missing data here)
Conclusion Differential views regarding medical abortion for SCD in Cameroon could lead to societal, ethical and legal conflicts. Our finding may well reflect the failure of professional stakeholders to provide adequate care services to patients with SCD in Cameroon.
The patient participants in this study indicated a surprisingly high (40.9%) rate of acceptability of TAP. This is surprising as one could argue that a decision to terminate a pregnancy where the future child would suffer from the same condition that is affecting the parent seems to imply a value judgment about the individuals’ quality of life. Patients who participated in this study presented with severe forms of SCD. We wonder whether our results mean that approximately 4 out of 10 of the patients included in this study did not find their quality of life worth living and did not want to allow a child to experience it. This is a disturbing finding that requires the further attention of policy makers and medical professionals in Cameroon.
Our finding may well reflect the failure of professional stakeholders to provide adequate care services to patients with SCD in Cameroon. For instance, the average late diagnosis of the condition in our participants leads to greater clinical severity. In addition, the very low number of people who receive adequate medical care to manage their condition, as well as the large number of people who received traditional medicine, may also indicate the failure of medical professionals in Cameroon to adequately manage SCD. Many patients with SCD require the expertise of specialized centers. Lifelong medical care and surveillance are not yet available in Cameroon where provision of healthcare services is hampered by major economic, organizational and infrastructural difficulties.These differential views of patients, physicians and parents also indicate potential ethical conflicts between various components of the Cameroonian society regarding TAP for SCD. Additional studies among various groups may provide detailed insight into the range of moral, legal and social perspectives held by the public and the healthcare community regarding genetic technology and prenatal diagnosis in Cameroon.