Public Health Action最新文献

Background: Médecins Sans Frontières Belgium installed point-of-care (POC) diagnostics for the early detection of advanced HIV disease (AHD), and in its presence, TB and cryptococcosis, in six health centres (Kasai, St Ambroise, St Joseph, Libondi, Lisanga and Kimia) in Kinshasa, Democratic Republic of the Congo (DRC).

Objective: To document their contribution to the diagnosis of these conditions.

Method: This is a retrospective cross-sectional study of HIV-positive adolescents and adults admitted with suspected AHD. A comparison 2 years before and 2 years after installation of POC was performed.

Results: A total of 745 and 887 patients were included before and after POC, respectively. The mean age was 39.7 years (standard deviation [SD] 12.04); 66% (n = 1,077) were women. Patients with CD4 counts increased from 40.3% (n = 300) to 64.4% (n = 573) (P < 0.001). After the installation of POC, they ranged from 47.8% (Lisanga) to 97.1% (Kasai). The proportion of AHD was comparable (n = 158, 52.7% vs. n = 288, 50.3%; P = 0.779). Among patients with AHD, TB was detected in 28.5% (n = 82), of which 41.5% (n = 34) were confirmed; cryptococcosis was detected in 24.7% (n = 71), of which 9.9% (n = 7) were confirmed. Disparities between centres were observed.

Conclusion: The POCs have increased patient access to CD4 testing and diagnosis of AHD in the six centres in DRC. However, actions are required to improve this performance, including screening for TB and cryptococcosis.

Background: In 2015, Médecins Sans Frontières opened the Arche Kigobe Trauma Centre in Bujumbura, Burundi, to treat victims of violence, and in 2016 extended the admission criteria to burns, without a specialised unit to treat these.

Objective: To study the factors associated with an unfavourable outcome (death, referrals and discharges against medical advice) in burn patients hospitalised at this centre.

Method: This is a retrospective descriptive and analytical study of hospitalised burn patients.

Results: From 2016 to 2020, 477 patients were hospitalised at the Centre for burns, of whom 301 (63%) were less than 5 years old, 169 (35%) were female, and 48 (10%) had an unfavourable outcome. Anaemia (OR 11, 95% CI 2.7-48), infection (OR 11, 95% CI 5.7-22), and smoke inhalation (OR 28, 95% CI 7-111) were among the main factors associated with an unfavourable outcome.

Conclusion: To minimise adverse outcomes related to inhalation and infection in burn patients, a septic isolation circuit, training, a bacteriology service and continuous positive airway pressure could be implemented even in resource-limited settings.

Background: Maternal mortality rates remain high (882/100,000 births) in the Central African Republic (CAR), primarily due to frequent obstetric complications. Médecins Sans Frontières supports a referral maternity ward in the capital, Bangui.

Objectives: To describe the prevalence, associated factors and fatality of one of the most severe complications, uterine rupture, as well as the effect of a history of uterine surgery.

Methods: This is a cross-sectional study based on retrospectively collected data between January 2018 and December 2021 for women who delivered new-borns weighing over 1,000 g.

Results: Of 38,782 deliveries, 229 (0.6%) cases of uterine rupture were recorded. Factors associated with uterine rupture were parity ⩾5 (adjusted odds ratio [aOR] 7.5, 95% confidence interval [CI] 4.6-12.2), non-occipital foetal presentation (aOR 2.8, 95% CI 2.1-3.7) and macrosomia (OR 4, 95% CI 2.6-6.4). The fatality rate was 4.4%, and the stillbirth rate was 64%. Uterine rupture occurred in non-scarred uterus in 150 (66.1%) women. Adverse outcomes were more common in cases of uterine rupture on non-scarred uterus compared to scarred uterus, with higher maternal mortality (6% vs. 0%, P = 0.023) and lower Apgar scores (<2) for new-borns (69.1% vs. 45.8%, P < 0.001).

Conclusion: Uterine rupture remains a major issue for maternal and perinatal health in the CAR, and efforts are needed to early detect risk factors and increase coverage of the comprehensive emergency obstetric and neonatal care.

Background: In a war-torn African country, Médecins Sans Frontières supports two regional referral hospitals to address emergencies, including the treatment of firearm-related traumas. It facilitates access to healthcare and referrals, which are often hindered due to non-medical reasons.

Objective: To determine the factors influencing the unfavourable outcome of cases referred for firearm trauma (December 2020-November 2021).

Method: This was a cross-sectional study using routinely collected data.

Results: A total of 381 patients who were victims of firearm-related trauma were admitted, with an average age of 29 years; 28.3% had severe injuries, including thoraco-abdominal injuries and fractures. The mortality rate was 4.9%, and 7.9% left against medical advice. Patients affiliated with the irregular armed forces accounted for 45.4%, and had a two-thirds higher rate of unsuccessful referral for non-medical reasons. Patients with severe injuries at triage, affiliation with the irregular forces and being in the regular army had 2 times (P < 0.01), 5.9 times (P < 0.01) and 8.1 times (P < 0.01), respectively, a higher risk of an unfavourable outcome.

Conclusion: Serious cases caused by firearm injuries were more likely to have an adverse outcome. The risk was higher in those with a specific affiliation, who were more often denied access to higher referral care based on socio-political rather than medical reasons.

Context: A unit supported by Médecins Sans Frontières (MSF) cares for patients with advanced HIV at Donka National Hospital, Conakry, Guinea.

Objective: To determine the factors associated with the occurrence of death in patients hospitalised in the unit between 2017 and 2021.

Design: This was a retrospective analysis of routine data from patients hospitalised with advanced HIV.

Results: A total of 3,718 patients were included, with a median age of 40 years (IQR 33-51), of whom 2,241 (60.3%) were women. The mean mortality rate was 33.6% (n = 1,240), down from 40% in 2017 to 29% in 2021, but this was not statistically significant. The period most at risk of death was the first 25 days of hospitalisation. Among these patients, TB (43.8%) and toxoplasmosis (11.4%) were the most frequent diagnoses. After multivariate analysis using Cox regression, the factors associated with death were age 25-49 years (adjusted hazard ratio [aHR] 1.60; P = 0.002) or ≥50 years (aHR 1.80; P < 0.001), the presence of respiratory (aHR 1.23; P = 0.001) or abdominal symptoms (aHR 1.26; P < 0.001) and readmission (aHR 0.54; P < 0.001).

Conclusion: Patients aged 25-49 years or older, or those presenting with respiratory or abdominal signs require increased surveillance, as they are at the greatest risk of dying from the disease, especially during the first 25 days of hospitalisation.

Context: Abdominal trauma (AT) appears to be frequent in Haiti, which is confronted with recurrent socio-political violence.

Objective: To study patients admitted for AT to the Médecins Sans Frontières (MSF) Tabarre trauma centre (Port-au-Prince), and the circumstances of occurrence.

Design: This was a cross-sectional study with retrospective data from January 2020 to December 2021.

Results: Of 3,211 patients admitted for trauma, 541 (17.3%) had an AT, of which 500 (91.4%) were related to sociopolitical events. Their median age was 30 years (interquartile range [IQR] 23-38); 429 (85.8%) were male. A gunshot wound was noted in 371 (74.2%). The median distance from the scene of violence to the hospital was 11 km (IQR 7-15); however, 9 (1.8%) came within 1 hour of the trauma; transfusion was not done or insufficient in 169 (33.8%). An adverse outcome (death, referral, discharge against medical advice) was noted in 57 (11.4%), with 8.0% of deaths. Political instability was the main cause of violence. An adverse outcome was associated with inadequate transfusion (hazard ratio [HR] 2.4, 95% CI 1.4-4.3; P = 0.006) or gunshot wound (HR 2.4, 95% CI 1.1-5.2; P = 0.002).

Conclusion: Firearm injuries were common during the period of sociopolitical events 2020-2021. The lack of blood products had a negative impact on patient outcomes. Safety measures and blood collection still need to be maintained and strengthened.

Background: This study was to meet a practical need to design a simple tool to identify TB patients who may potentially be facing catastrophic costs while seeking TB care in the public sector. Such a tool may help prevent and address catastrophic costs among individual patients.

Methods: We used data from the national TB patient cost survey in the Philippines. We randomly allocated TB patients to either the derivation or validation sample. Using adjusted odds ratios (ORs) and β coefficients of logistic regression, we developed four scoring systems to identify TB patients who may be facing catastrophic costs from the derivation sample. We validated each scoring system in the validation sample.

Results: We identified a total of 12 factors as predictive indicators associated with catastrophic costs. Using all 12 factors, the β coefficients-based scoring system (area under the curve [AUC] 0.783, 95% CI 0.754-0.812) had a high validity. Even with seven selected factors with OR > 2.0, the validity remained in the acceptable range (β coefficients-based: AUC 0.767, 95% CI 0.737-0.798).

Conclusion: The β coefficients-based scoring systems in this analysis can be used to identify those at high risk of facing catastrophic costs due to TB in the Philippines. Operational feasibility needs to be investigated further to implement this in routine TB surveillance.

A rising number of diphtheria cases were recorded in Europe in 2022, including in Belgium, within the newly arriving young migrant population. In October 2022, Médecins Sans Frontières (MSF) opened a temporary roadside container-clinic offering free medical consultations. Over 3 months of activity, the temporary clinic detected 147 suspected cases of cutaneous diphtheria with 8 laboratory-confirmed cases growing toxigenic Corynebacterium diphtheriae. This was followed by a mobile vaccination campaign, during which 433 individuals living rough in squats and informal shelters were vaccinated. This intervention has shown how even in Europe's capital, access to preventive and curative medical services remains difficult for those who need it the most. Appropriate access to health services, including routine vaccination, are crucial to improve the health status among migrants.

Setting: The COVID-19 pandemic has caused disruptions to healthcare services worldwide, including in private healthcare facilities (HCFs), where TB patients mostly initiate their care-seeking journey.

Objective: To identify adjustments to TB-related practices made by HCFs during the pandemic.

Design: We identified, contacted and invited private HCFs across West Java, Indonesia, to fill an online questionnaire. The questionnaire explored participants' sociodemographic characteristics, adaptations and TB management practices implemented in their facilities during the pandemic. Data were analysed using descriptive statistics.

Results: Of the 240 HCFs surveyed, 40.0% shortened their operational hours and 21.3% have ever closed their practices during the pandemic; 217 (90.4%) made adjustments to keep delivering services, 77.9% by requiring the use of personal protective equipment (PPE); 137 (57.1%) observed fewer patient visits; 140 (58.3%) used telemedicine, a few of which (7.9%) ever handled TB patients on that platform. Respectively 89.5%, 87.5% and 73.3% of HCFs referred patients for chest radiography, smear microscopy and Xpert testing. Only a median of 1 (IQR 1-3) TB patient per month was diagnosed by the HCFs.

Conclusion: Two major adaptations rolled out during COVID-19 were the use of telemedicine and PPE. Optimisation of the diagnostic referral system to increase TB case detection in private HCFs is warranted.