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Klassen SL, Okello E, Ferrer JME, Alizadeh F, Barango P, Chillo P, Chimalizeni Y, Dagnaw WW, Eiselé JL, Eberly L, Gomanju A, Gupta N, Koirala B, Kpodonu J, Kwan G, Mailosi BGD, Mbau L, Mutagaywa R, Pfaff C, Piñero D, Pinto F, Rusingiza E, Sanni UA, Sanyahumbi A, Shakya U, Sharma SK, Sherpa K, Sinabulya I, Wroe EB, Bukhman G, Mocumbi A. Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease. Glob Heart 2024; 19:33. [PMID: 38549727 PMCID: PMC10976983 DOI: 10.5334/gh.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/27/2024] [Indexed: 04/02/2024] Open
Abstract
Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.
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Affiliation(s)
- Sheila L. Klassen
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, United States
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, United States
| | - Emmy Okello
- Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Faraz Alizadeh
- Department of Cardiology, Boston Children’s hospital, Boston, United States
- Department of Pediatrics, Harvard Medical School, Boston, United States
| | - Prebo Barango
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Pilly Chillo
- Muhimbili University of Health and Allied Sciences, Department of Internal Medicine, Dar Es Salaam, Tanzania
| | - Yamikani Chimalizeni
- Kamuzu University of Health Sciences, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Wubaye Walelgne Dagnaw
- Center for Integration Science, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, United States
| | | | - Lauren Eberly
- Division of Cardiovascular Medicine, Department of Medicine, Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, Penn Cardiovascular Center for Health, University of Pennsylvania, Philadelphia, United States
| | - Anu Gomanju
- Kathmandu Institute of Child Health, Kathmandu, Nepal
- Global Alliance for Rheumatic and Congenital Hearts, Philadelphia, United States
| | - Neil Gupta
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, United States
- Department of Global Health and Social Medicine, Program in Global NCDs and Social Change, Harvard University, Boston, United States
| | - Bhagawan Koirala
- Department of Cardiothoracic & Vascular Surgery – Manmohan Cardiothoracic Vascular and Transplant Centre, Kathmandu, Nepal
| | - Jacques Kpodonu
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, United States
| | - Gene Kwan
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, United States
- Partners In Health, Boston, United States
- Department of Global Health and Social Medicine, Harvard University, Boston, United States
| | | | | | - Reuben Mutagaywa
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Colin Pfaff
- Center for Integration Science, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, United States
| | - Daniel Piñero
- Departamento de Ecología Evolutiva, Instituto de Ecología, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | - Fausto Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Emmanuel Rusingiza
- Department of Pediatrics, Pediatric Cardiology Unit, University Teaching Hospital of Kigali, Kigali, Rwanda
- College of Medicine and Health Sciences, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Usman Abiola Sanni
- Partners in Health, Sierra Leone
- Department of Paediatrics, Federal Medical Centre, Birnin Kebbi, Nigeria
| | - Amy Sanyahumbi
- Pediatric Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, United States
- Baylor Center of Excellence, Lilongwe, Malawi
| | - Urmila Shakya
- Pediatric Cardiology Department, Shahid Gangalal National Heart Centre, Kathmandu, Nepal
- National Academy of Medical Sciences, Kathmandu, Nepal
| | - Sanjib Kumar Sharma
- Cardiology and Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Kunjang Sherpa
- Department of Cardiology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal
| | - Isaac Sinabulya
- Department of Medicine, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Emily B. Wroe
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, United States
| | - Gene Bukhman
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, United States
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, United States
- Department of Global Health and Social Medicine, Harvard University, Boston, United States
| | - Ana Mocumbi
- Universidade Eduardo Mondlane, Maputo, Mozambique
- Instituto Nacional de Saúde, Maputo, Mozambique
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Mebrahtom G, Hailay A, Aberhe W, Zereabruk K, Haile T. Rheumatic Heart Disease in East Africa: A Systematic Review and Meta-Analysis. Int J Rheumatol 2023; 2023:8834443. [PMID: 37767221 PMCID: PMC10522432 DOI: 10.1155/2023/8834443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/29/2023] Open
Abstract
Background Despite being a grave problem, there is little information on rheumatic heart disease's prevalence in East Africa. Therefore, the purpose of this systematic review and meta-analysis was to estimate the pooled prevalence of rheumatic heart disease in East Africa. Materials and Methods A computerized systematic search of using multiple database searching engines was performed in search of relevant English articles from the inception of the databases to December 2019. It was done in accordance with the preferred reporting items for systematic review and meta-analysis (PRISMA) standard. The funnel plot was used to assess publication bias. R and RStudio for Windows were used for all statistical analysis. The random-effect model was used for calculating the pooled estimate of the prevalence of rheumatic heart disease. Results The database search retrieved 1073 papers, and 80 articles (78 cross-sectional and two cohort study designs) with a total of 184575 individuals were found to be appropriate for the review. In East Africa, the overall prevalence of rheumatic heart disease was 14.67% (95% CI: 13.99% to 15.35%). In Ethiopia, Uganda, Tanzania, and Sudan, respectively, the subgroup analysis of rheumatic heart disease pooled prevalence was 22% (95% CI: 13% to 36%), 11% (95%t CI: 5% to 20%), 9% (95%t CI: 5% to 16%), and 3% (95%t CI: 1% to 10%), while the pooled prevalence of rheumatic heart disease in adults was 20% (95% CI: 12% to 30%), and in children, it was 4% (95% CI: 2% to 8%). Conclusions From this report, the prevalence of rheumatic heart disease in East Africa is very high, affecting about one in seven people. Therefore, future strategies should emphasize preventive measures at appropriate times to minimize the burden of this type of preventable heart disease.
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Affiliation(s)
- Guesh Mebrahtom
- Department of Adult Health Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
| | - Abrha Hailay
- Department of Adult Health Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
| | - Woldu Aberhe
- Department of Adult Health Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
| | - Kidane Zereabruk
- Department of Adult Health Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
| | - Teklehaimanot Haile
- Department of Maternity and Neonatal Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
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Klassen SL, Dusingizimana W, Ngoga G, Kamali I, Dusabeyezu S, Ntaganda E, Kwan GF. Using Point-of-Care Ultrasound in Heart Failure Diagnosis and Management in Rural and Resource-Limited Settings. CASE (PHILADELPHIA, PA.) 2022; 6:259-262. [PMID: 36036046 PMCID: PMC9399555 DOI: 10.1016/j.case.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
•RHD is a common cause of heart failure in sub-Saharan Africa. •Task shifting by training rural providers in POCUS improves cardiac imaging access. •POCUS in low-resource settings can determine presence of structural heart disease. •There are specific POCUS device considerations for use in low-resource settings. •POCUS use in rural low-resource settings can lead to early heart failure management.
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Affiliation(s)
- Sheila L. Klassen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Center for Integration Science, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Gedeon Ngoga
- Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | - Gene F. Kwan
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
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Gtif I, Bouzid F, Charfeddine S, Abid L, Kharrat N. Heart failure disease: An African perspective. Arch Cardiovasc Dis 2021; 114:680-690. [PMID: 34563468 DOI: 10.1016/j.acvd.2021.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
Heart failure remains a health challenge in Africa, associated with significant rates of hospitalization, morbidity and mortality. The current review aims to summarize the most recent data on the epidemiology, aetiology, risk factors and management of heart failure, comparing countries in North Africa and sub-Saharan Africa. There is a paucity of data on heart failure epidemiology, aetiology and management, and on the sociodemographic characteristics of African patients with heart failure. Heart failure prevalence has been evaluated among all medical admissions or admissions to cardiac units or emergency departments in a few hospital-based studies conducted in countries in North Africa and sub-Saharan Africa. Common causes of heart failure in Africa include ischaemic heart disease, hypertensive heart disease, dilated cardiomyopathy and valvular heart disease. The aetiology of heart failure differs between countries in North Africa and sub-Saharan Africa. Diagnosing heart failure proves challenging in Africa because of a lack of basic tools and the necessary human resources. The principal drugs used frequently for heart failure therapy are lacking in sub-Saharan Africa. The clinical profile of heart failure in sub-Saharan Africa differs from that in North African countries; this is related to aetiological factors, socioeconomic status and availability of diagnostic tools. There is an evident need to establish a large multicentre registry to evaluate the heart failure burden in almost all African countries, and to highlight the major cardiovascular risk factors and co-morbidities. The present review highlights the importance of this syndrome in Africa, and calls for improvements in its early diagnosis, treatment and, possibly, prevention.
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Affiliation(s)
- Imen Gtif
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour, 3061 Sfax, Tunisia.
| | - Fériel Bouzid
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour, 3061 Sfax, Tunisia
| | - Salma Charfeddine
- Department of Cardiology, Hédi Chaker University Hospital, Faculty of Medicine of Sfax, University of Sfax, 3000 Sfax, Tunisia
| | - Leila Abid
- Department of Cardiology, Hédi Chaker University Hospital, Faculty of Medicine of Sfax, University of Sfax, 3000 Sfax, Tunisia
| | - Najla Kharrat
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour, 3061 Sfax, Tunisia
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Postoperative Rheumatic Heart Disease Follow-Up: Creating a National Registry and First Results from Rwanda. Ann Glob Health 2020; 86:115. [PMID: 32963968 PMCID: PMC7485403 DOI: 10.5334/aogh.2719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background In many developing countries, rheumatic heart disease (RHD) is diagnosed at an advanced stage and requires surgery for patient survival. However, access to cardiac surgery in this context is limited and often provided through partnerships, requiring centralized patient data systems for monitoring and follow-up. Objectives This study used data from a national postoperative RHD registry to analyze clinical outcomes of Rwandan patients who received surgery between 2006 and 2017. Methods The RHD registry was created in 2017 using data compiled from Rwanda Ministry of Health and RHD surgery partners. We extracted pre- and post-operative data on patients who were alive and in care. We excluded patients who died or were lost to follow-up, as their data was not collected in the registry. We evaluated the association between demographic, surgical, and follow-up characteristics and most recent patient symptoms, categorized by New York Heart Association (NYHA) class. Findings Among the 191 patients eligible for inclusion in this study, 107(56.0%) were female, 110(57.6%) were adults at the time of surgery (>15 years), and 128(67.4%) had surgery in Rwanda. Most patients (n = 166, 86.9%) were on penicillin prophylaxis. Of the patients with mechanical valves, 47(29.9%) had therapeutic International Normalized Ratio values. 90% of patients were asymptomatic (NYHA I) at the time of most recent visit. NYHA class was not significantly associated with any of the considered variables. The median length of follow-up for patients was four years (IQR: 2, 5 years). Conclusion This study shows both the feasibility and challenges of creating a RHD registry 11 years after the national initiation of RHD surgeries. Most patients captured in the registry are asymptomatic; however, collecting details on patients who had died or were lost to follow-up has proven difficult. Implementing strategies to maintain a complete and up-to-date registry will facilitate follow-up for pre- and postoperative patients.
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Ng'ang'a L, Ngoga G, Dusabeyezu S, Hedt-Gauthier BL, Ngamije P, Habiyaremye M, Harerimana E, Ndayisaba G, Rusangwa C, Niyonsenga SP, Bavuma CM, Bukhman G, Adler AJ, Kateera F, Park PH. Implementation of blood glucose self-monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda: 6 months open randomised controlled trial. BMJ Open 2020; 10:e036202. [PMID: 32718924 PMCID: PMC7389513 DOI: 10.1136/bmjopen-2019-036202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Most patients diagnosed with diabetes in sub-Saharan Africa (SSA) present with poorly controlled blood glucose, which is associated with increased risks of complications and greater financial burden on both the patients and health systems. Insulin-dependent patients with diabetes in SSA lack appropriate home-based monitoring technology to inform themselves and clinicians of the daily fluctuations in blood glucose. Without sufficient home-based data, insulin adjustments are not data driven and adopting individual behavioural change for glucose control in SSA does not have a systematic path towards improvement. METHODS AND ANALYSIS This study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group-participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group-participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG. The primary outcomes are change in haemoglobin A1c, fidelity to SMBG protocol by patients, appropriateness and adverse effects resulting from SMBG. Secondary outcomes include reliability and acceptability of SMBG and change in the quality of life of the participants. ETHICS AND DISSEMINATION This study has been approved by the Rwanda National Ethics Committee (Kigali, Rwanda No.102/RNEC/2018). We will disseminate the findings of this study through presentations within our study settings, scientific conferences and publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER PACTR201905538846394; pre-results.
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Affiliation(s)
- Loise Ng'ang'a
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | - Gedeon Ngoga
- Non-Communicable Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
| | - Symaque Dusabeyezu
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | | | - Patient Ngamije
- Kirehe District Hospital, Ministry of Health, Kigali, Rwanda
| | | | | | - Gilles Ndayisaba
- Non-Communicable Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Christian Rusangwa
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | | | - Charlotte M Bavuma
- Internal Medicine, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Gene Bukhman
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alma J Adler
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Fredrick Kateera
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | - Paul H Park
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Ajayi AA, Sofowora GG, Ladipo GO. Explaining Heart Failure Hyper-mortality in Sub Saharan Africa: Global Genomic and Environmental Contribution Review. J Natl Med Assoc 2020; 112:141-157. [PMID: 32165009 DOI: 10.1016/j.jnma.2020.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 12/11/2022]
Abstract
The annual heart failure (HF) mortality rate in Africa is 34% according to the INTERHF study. This is twice the world average of 16.5% and 3.7 times that of South America, 9%. We review evidence-based explanations for the Hyper-mortality of HF, by comparison of North American, Caribbean, Afro-Brazilian with Sub-Saharan African (SSA) nations profiles, and suggest amelioration. 1 year HF mortality rates in SSA ranged from 29% to 58%, and intra-hospital mortality rate from 8 to 26% (n = 8). A clustering of adverse genetic single nucleotide polymorphisms (SNP) predisposing to hypertension and/or left ventricular hypertrophy (LVH) in the black diaspora may contribute. A higher prevalence of HF with reduced Ejection Fraction (HF r EF) phenotype, which is associated with greater mortality is more common in SSA nations. Additionally, a worse co-morbidity burden, especially valvular regurgitations causing LV remodeling (LVR), chronic kidney disease (CKD), anemia, lung disease, infections, late presentation in NYHA III/IV, right ventricular disease (RVD) were also common in SSA. Geographic variation in SSA, HF risk factors and co-morbidity was observed. There was sub-optimal use of guideline directed medical therapy (GDMT) and intracardiac device (ICD) unavailability. Gross Domestic Product -per purchasing power parity (GDP-PPP), which is low in SSA, was inversely correlated both to higher intra-hospital mortality rate % (r = -0.73, r 2 = 0.54 p = 0.038) and higher 1 year HF mortality rate % (r = -0.62, r 2 = 0.38, = 0.098). Localized primary prevention, early detection and prompt treatment of hypertension, diabetes, rheumatic fever, early cardiac valve repair and use of cardiovascular polypill, optimal use of GDMT, national health insurance scheme are advocated to stem the dismal mortality and cost burden of HF.
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Affiliation(s)
- Adesuyi A Ajayi
- Adjunct Professor, Department of Medicine, Division of Hypertension and Clinical Pharmacology, Baylor College of Medicine, Houston, TX, 77060, USA.
| | - Gbemiga G Sofowora
- Associate Professor of Cardiology, Cardiovascular Medicine Division, Ohio State University Medical Center, Columbus, OH, 43210, USA
| | - Gani O Ladipo
- Retired Professor of Cardiology, Obafemi Awolowo University, Ile -ife, Osun State, Nigeria
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Cardiovascular Diseases in Sub-Saharan Africa Compared to High-Income Countries: An Epidemiological Perspective. Glob Heart 2020; 15:15. [PMID: 32489788 PMCID: PMC7218780 DOI: 10.5334/gh.403] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Non-communicable diseases (NCDs) are the second common cause of death in sub-Saharan Africa (SSA) accounting for about 35% of all deaths, after a composite of communicable, maternal, neonatal, and nutritional diseases. Despite prior perception of low NCDs mortality rates, current evidence suggests that SSA is now at the dawn of the epidemiological transition with contemporary double burden of disease from NCDs and communicable diseases. In SSA, cardiovascular diseases (CVDs) are the most frequent causes of NCDs deaths, responsible for approximately 13% of all deaths and 37% of all NCDs deaths. Although ischemic heart disease (IHD) has been identified as the leading cause of CVDs mortality in SSA followed by stroke and hypertensive heart disease from statistical models, real field data suggest IHD rates are still relatively low. The neglected endemic CVDs of SSA such as endomyocardial fibrosis and rheumatic heart disease as well as congenital heart diseases remain unconquered. While the underlying aetiology of heart failure among adults in high-income countries (HIC) is IHD, in SSA the leading causes are hypertensive heart disease, cardiomyopathy, rheumatic heart disease, and congenital heart diseases. Of concern is the tendency of CVDs to occur at younger ages in SSA populations, approximately two decades earlier compared to HIC. Obstacles hampering primary and secondary prevention of CVDs in SSA include insufficient health care systems and infrastructure, scarcity of cardiac professionals, skewed budget allocation and disproportionate prioritization away from NCDs, high cost of cardiac treatments and interventions coupled with rarity of health insurance systems. This review gives an overview of the descriptive epidemiology of CVDs in SSA, while contrasting with the HIC and highlighting impediments to their management and making recommendations.
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Kwan GF, Yan LD, Isaac BD, Bhangdia K, Jean-Baptiste W, Belony D, Gururaj A, Martineau L, Vertilus S, Pierre-Louis D, Fenelon DL, Hirschhorn LR, Benjamin EJ, Bukhman G. High Poverty and Hardship Financing Among Patients with Noncommunicable Diseases in Rural Haiti. Glob Heart 2020; 15:7. [PMID: 32489780 PMCID: PMC7218772 DOI: 10.5334/gh.388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/19/2019] [Indexed: 11/25/2022] Open
Abstract
Background Poverty is a major barrier to healthcare access in low-income countries. The degree of equitable access for noncommunicable disease (NCD) patients is not known in rural Haiti. Objectives We evaluated the poverty distribution among patients receiving care in an NCD clinic in rural Haiti compared with the community and assessed associations of poverty with sex and distance from the health facility. Methods We performed a cross-sectional study of patients with NCDs attending a public-sector health center in rural Haiti 2013-2016, and compared poverty among patients with poverty among a weighted community sample from the Haiti 2012 Demographic and Health Survey. We adapted the multidimensional poverty index: people deprived ≥44% of indicators are among the poorest billion people worldwide. We assessed hardship financing: borrowing money or selling belongings to pay for healthcare. We examined the association between facility distance and poverty adjusted for age and sex using linear regression. Results Of 379 adults, 72% were women and the mean age was 52.5 years. 17.7% had hypertension, 19.3% had diabetes, 3.1% had heart failure, and 33.8% had multiple conditions. Among patients with available data, 197/296 (66.6%) experienced hardship financing. The proportions of people who are among the poorest billion people for women and men were similar (23.3% vs. 20.3%, p > 0.05). Fewer of the clinic patients were among the poorest billion people compared with the community (22.4% vs. 63.1%, p < 0.001). Patients who were most poor were more likely to live closer to the clinic (p = 0.002). Conclusion Among patients with NCD conditions in rural Haiti, poverty and hardship financing are highly prevalent. However, clinic patients were less poor compared with the community population. These data suggest barriers to care access particularly affect the poorest. Socioeconomic data must be collected at health facilities and during community-level surveillance studies to monitor equitable healthcare access. Highlights Poverty and hardship financing are highly prevalent among NCD patients in rural Haiti.Patients attending clinic are less poor than expected from the community.People travelling farther to clinic are less poor.Socioeconomic data should be collected to monitor healthcare access equity.
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Affiliation(s)
- Gene F. Kwan
- Boston University School of Medicine, Boston, MA, US
- Boston Medical Center, Boston, MA, US
- Partners In Health, Boston, MA, US
- Harvard Medical School, Boston, MA, US
| | | | | | | | | | | | | | - Louine Martineau
- Zanmi Lasante, HT
- Tufts New England Medical Center, Boston, MA, US
| | - Serge Vertilus
- Zanmi Lasante, HT
- Hôpital Universitaire de Mirebalais, HT
| | | | | | | | - Emelia J. Benjamin
- Boston University School of Medicine, Boston, MA, US
- Boston University School of Public Health, Boston, MA, US
| | - Gene Bukhman
- Harvard Medical School, Boston, MA, US
- Brigham and Women’s Hospital, Boston, MA, US
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Eberly LA, Rusingiza E, Park PH, Ngoga G, Dusabeyezu S, Mutabazi F, Gahamanyi C, Ntaganda E, Kwan GF, Bukhman G. 10-Year Heart Failure Outcomes From Nurse-Driven Clinics in Rural Sub-Saharan Africa. J Am Coll Cardiol 2020; 73:977-980. [PMID: 30819366 DOI: 10.1016/j.jacc.2018.12.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 11/17/2022]
Abstract
Nurse-led delivery care models have the potential to address the significant burden of heart failure in sub-Saharan Africa. Starting in 2006, the Rwandan Ministry of Health, supported by Inshuti Mu Buzima (Partners In Health-Rwanda), decentralized heart failure diagnosis and care delivery in the context of advanced nurse-led integrated noncommunicable clinics at rural district hospitals. Here, the authors describe the first medium-term survival outcomes from the district level in rural sub-Saharan Africa based on their 10-year experience providing care in rural Rwanda. Kaplan-Meier methods were used to determine median time to event for: 1) composite event of known death from any cause, lost to follow-up, or transfer to estimate worst-case mortality; and 2) known death only. Five-year event-free rates were 41.7% for the composite outcome and 64.3% for known death. While death rates are encouraging, efforts to reduce loss to follow-up are needed.
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Affiliation(s)
- Lauren A Eberly
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emmanuel Rusingiza
- Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - Paul H Park
- Partners in Health, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Gene F Kwan
- Partners in Health, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Section of Cardiology, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Gene Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Partners in Health, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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Abstract
PURPOSE OF REVIEW Acute heart failure (AHF) is a common emergency presentation in Sub-Saharan Africa (SSA). In the current review, we present the most recent data on the epidemiology of AHF in SSA and discuss recommended approaches to management in resource-limited settings, with a particular focus on primary and secondary facilities (e.g., health centers and district hospitals), where these patients often present. RECENT FINDINGS AHF in SSA is most often due to hypertension, cardiomyopathies, and rheumatic heart disease. The etiology of AHF may be different in rural as compared with urban settings. Diagnostic tools for AHF are often lacking in SSA, especially at the first-level facilities. Point-of-care ultrasound (POCUS) and biomarker tests, such as brain natriuretic peptide (BNP), offer promise in helping to mitigate diagnostic challenges. POCUS can also help distinguish among types of heart failure and prompt the correct treatment strategy. Many of the drugs and equipment commonly used to treat AHF in resource-rich settings are lacking in SSA. However, some adaptations of commonly available materials may provide temporary alternatives. The epidemiology of AHF in SSA differs from that of high-income settings. Management of AHF at the first-level facility in SSA is an important and understudied problem. Simplified diagnostic and treatment algorithms rooted in knowledge of the local epidemiology should be developed and tested as part of broader efforts to combat cardiovascular disease in SSA.
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Mensah GA. Heart Failure in Low-Income and Middle-Income Countries: Rising Burden, Diverse Etiology, and High Mortality. J Card Fail 2019; 24:833-834. [PMID: 30527333 DOI: 10.1016/j.cardfail.2018.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
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Okello S, Abeya FC, Lumori BAE, Akello SJ, Moore CC, Annex BH, Buda AJ. Validation of heart failure quality of life tool and usage to predict all-cause mortality in acute heart failure in Uganda: the Mbarara heart failure registry (MAHFER). BMC Cardiovasc Disord 2018; 18:232. [PMID: 30541443 PMCID: PMC6291962 DOI: 10.1186/s12872-018-0959-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/19/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The health-related quality of life (HRQoL) is an important treatment goal that could serve as low-cost prognostication tool in resource poor settings. We sought to validate the Kansas City Cardiomyopathy Questionnaire (KCCQ) and evaluate its use as a predictor of 3 months all-cause mortality among heart failure participants in rural Uganda. METHODS The Mbarara Heart Failure Registry Cohort study observes heart failure patients during hospital stay and in the community in rural Uganda. Participants completed health failure evaluations and HRQoL questionnaires at enrollment, 1 and 3 months of follow-up. We used Cronbach's alpha coefficients to define internal consistency, intraclass correlation coefficients as a reliability coefficient, and Cox proportional hazard models to predict the risk of 3 months all-cause mortality. RESULTS Among the 195 participants who completed HRQoL questionnaires, the mean age was 52 (standard deviation (SD) 21.4) years, 68% were women and 29% reported history of hypertension. The KCCQ had excellent internal consistency (87% Cronbach alpha) but poor reliability. Independent predictors of all-cause mortality within 3 months included: worse overall KCCQ score (Adjusted Hazard ratio (AHR) 2.9, 95% confidence interval (CI) 1.1, 8.1), highest asset ownership (AHR 3.6, 95% CI 1.2, 10.8), alcoholic drinks per sitting (AHR per 1 drink 1.4, 95% CI 1.0, 1.9), New York Heart Association (NYHA) functional class IV heart failure (AHR 2.6, 95% CI 1.3, 5.4), estimated glomerular filtration rate (eGFR) 30 to 59 ml/min/1.73 m2 (AHR 3.4, 95% CI 1.1, 10.8), and eGFR less than 15 ml/min/1.73 m2 (AHR 2.7, 95% CI 1.0, 7.1), each 1 pg/mL increase in Brain Natriuretic Peptide (BNP) (AHR, 1.0, 95% CI 1.0, 1.0), and each 1 ng/mL increase in Creatine-Kinase MB isomer (CKMB) (AHR 1.0, 95% CI 1.0, 1.1). CONCLUSION The KCCQ showed excellent internal consistency. Worse overall KCCQ score, highest asset ownership, increasing alcoholic drink per sitting, NYHA class IV, decreased estimated glomerular filtration rate, BNP, and CKMB predicted all-cause mortality at 3 months. The KCCQ could be an additional low-cost tool to aid in the prognostication of acute heart failure patients.
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Affiliation(s)
- Samson Okello
- Department of Internal Medicine, Mbarara University of Science and Technology, P. O Box 1410, Mbarara, Uganda
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
- Bernard Lown Scholars in Cardiovascular Health Program, Department of Global Health and Populations, Harvard T.H Chan School of Public Health, Boston, MA USA
| | - Fardous Charles Abeya
- Department of Internal Medicine, Mbarara University of Science and Technology, P. O Box 1410, Mbarara, Uganda
| | | | - Suzan Joan Akello
- Department of Educational Foundations and Psychology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Christopher Charles Moore
- Department of Internal Medicine, Mbarara University of Science and Technology, P. O Box 1410, Mbarara, Uganda
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Brian H. Annex
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Andrew J. Buda
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
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