A multinational and multidisciplinary approach to treat CHD in paediatric age in Angola: initial experience of a medical-surgical centre for children with heart disease in Angola

The burden, prevention and care of infants and children with congenital anomalies in sub-Saharan Africa: A scoping review

The aim of this scoping review was to determine the scope, objectives and methodology of contemporary published research on congenital anomalies (CAs) in sub-Saharan Africa (SSA), to inform activities of the newly established sub-Saharan African Congenital Anomaly Network (sSCAN). MEDLINE was searched for CA-related articles published between January 2016 and June 2021. Articles were classified into four main areas (public health burden, surveillance, prevention, care) and their objectives and methodologies summarized. Of the 532 articles identified, 255 were included. The articles originated from 22 of the 49 SSA countries, with four countries contributing 60% of the articles: Nigeria (22.0%), Ethiopia (14.1%), Uganda (11.7%) and South Africa (11.7%). Only 5.5% of studies involved multiple countries within the region. Most articles included CA as their primary focus (85%), investigated a single CA (88%), focused on CA burden (56.9%) and care (54.1%), with less coverage of surveillance (3.5%) and prevention (13.3%). The most common study designs were case studies/case series (26.6%), followed by cross-sectional surveys (17.6%), retrospective record reviews (17.3%), and cohort studies (17.2%). Studies were mainly derived from single hospitals (60.4%), with only 9% being population-based studies. Most data were obtained from retrospective review of clinical records (56.1%) or via caregiver interviews (34.9%). Few papers included stillbirths (7.5%), prenatally diagnosed CAs (3.5%) or terminations of pregnancy for CA (2.4%).This first-of-a-kind-scoping review on CA in SSA demonstrated an increasing level of awareness and recognition among researchers in SSA of the contribution of CAs to under-5 mortality and morbidity in the region. The review also highlighted the need to address diagnosis, prevention, surveillance and care to meet Sustainable Development Goals 3.2 and 3.8. The SSA sub-region faces unique challenges, including fragmentation of efforts that we hope to surmount through sSCAN via a multidisciplinary and multi-stakeholder approach.

International pediatric surgery partnerships in sub-Saharan Africa: a scoping literature review

Background

Sub-Saharan Africa (SSA) faces a critical shortage of pediatric surgical providers. International partnerships can play an important role in pediatric surgical capacity building but must be ethical and sustainable.

Objective

The purpose of this study is to perform a scoping literature review of international pediatric surgery partnerships in SSA from 2009 to 2019. We aim to categorize and critically assess past partnerships to aid in future capacity-building efforts.

Methods

We performed a scoping literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. We searched the PubMed and Embase databases for articles published from 2009 to 2019 using 24 keywords. Articles were selected according to inclusion criteria and assessed by two readers. Descriptive analyses of the data collected were conducted in Excel.

Results

A total of 2376 articles were identified. After duplicates were removed, 405 articles were screened. In total, 83 articles were assessed for eligibility, and 62 were included in the review. The most common partnership category was short-term surgical trip (28 articles, 45%). A total of 35 articles (56%) included education of host country providers as part of the partnership. Only 45% of partnerships included follow-up care, and 50% included postoperative outcomes when applicable.

Conclusions

To increase sustainability, more partnerships must include education of local health-care providers, and short-term surgical trips must be integrated into long-term partnerships. More partnerships need to report postoperative outcomes and ensure follow-up care. Educating peri-operative providers, training general surgeons in common pediatric procedures, and increasing telehealth use are other goals for future partnerships.

Capacity-building partnerships for surgical post-graduate training in low- and middle-income countries: a scoping review of the literature with exploratory thematic synthesis

In recent years, international surgical programmes have moved away from vertical service delivery and towards collaborative, capacity-building partnerships. The aim of this review was to provide a map of the current literature on international surgical training partnerships together with an exploration of factors influencing their implementation. Three bibliographic databases were searched for peer-reviewed reports of surgical training partnerships between organizations in high- and low or middle-income countries to July 2018. Reports were sorted in an iterative fashion into groups of similar programmes, and data were extracted to record the intervention strategies, context, financing, reported results and themes around implementation. Eighty-six reports were grouped into five types of programme: full residency training, bi-institutional twinning partnerships, diagonal/sub-specialist programmes, focused interventions or courses and programmes using remote support. Few articles were written from the perspective of the low-middle income partner. Full residency programmes and some diagonal/sub-specialist programmes report numbers trained while twinning partnerships and focused interventions tend to focus on process, partners' reactions to the programme and learning metrics. Two thematic networks emerged from the thematic synthesis. The first made explicit the mechanisms by which partnerships are expected to contribute to improved access to surgical care and a second identified the importance of in-country leadership in determining programme results. Training partnerships are assumed to improve access to surgical care by a number of routes. A candidate programme theory is proposed together with some more focused theories that could inform future research. Supporting the development of the surgical leadership in low- and middle-income countries is key.

Current Status of Training and Certification for Congenital Heart Surgery Around the World: Proceedings of the Meetings of the Global Council on Education for Congenital Heart Surgery of the World Society for Pediatric and Congenital Heart Surgery

The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve the quality of care for patients with Congenital Heart Disease worldwide. The purpose of this article is to summarize and document the present state of training and certification in congenital heart surgery around the world.

Challenges of Caring for Functionally Single Ventricle Patients in Africa

Surgical palliation has remarkably improved survival of functionally single ventricle (FSV) patients born in developed nations but such outcomes have not occurred in Africa. The poor care coverage for FSV patients in Africa exists within the larger sphere of deficient health care for children born with congenital heart defects (CHDs) in Africa generally. This review takes the position that to improve health-care coverage for CHD patients on the continent, political priority is paramount. This can be attained with cohesive leadership for the CHD agenda, a guiding institution, and the mobilization of civil society to drive advocacy at national and international levels.

Workforce Cost Model for Expanding Congenital and Rheumatic Heart Disease Services in Kenya

BACKGROUND

Cardiovascular disease is the number one global killer, with over three quarters of these deaths arising from the populations of low- and middle-income countries (LMICs). Addressing the burden of cardiovascular disease in LMICs must include medical and surgical services for these patients. In this article, we model the needs and costs to scale up the cardiac provider workforce in Kenya, which can be adapted to other LMICs based on country-specific workforce hours and workforce salaries.

METHODS

Using published epidemiological reports from sub-Saharan Africa, we structured the model based on the expected disease burden of congenital and rheumatic disease in a simulated 1,000-person population. Services modeled include clinic visits, echocardiograms, diagnostic cardiac catheterizations, interventional catheterizations, and heart surgery. Costs were modeled based on Kenyan public sector salaries. After scaling the model, we created a sensitivity analysis of change in service duration and salaries.

RESULTS

Based on a 1,000-person Kenyan population, we estimate that 2.5 heart surgeries will be needed every year, with a corresponding annual workforce cost of US$526. Including accompanying services of clinic visits, echocardiograms, and both diagnostic and interventional cardiac catheterizations, the total annual workforce cost is US$899. Based on estimated productive hours for public sector workforce, 196 full-time equivalent cardiac surgeons will be needed for the entire population of Kenya (2017 figure).

CONCLUSIONS

We present a model for appropriate cardiovascular service staffing based on disease burden and workforce costs. This model can be scaled up as needed to plan for local capacity building.

Palliation of Functionally Single Ventricle Patients in Sub-Saharan Africa-Is It Justifiable?

Resource constraints in many sub-Saharan African countries undermine efforts to provide the full spectrum of pediatric cardiology and cardiac surgery. Palliation of the child born with functionally single ventricle is the lowest priority for policymakers when viewed from the perspective of cost-effectiveness. This commentary focuses on the relative importance of different criteria that policymakers and the general public consider important in setting health-care priorities as it relates to palliation of the patient with functionally single ventricle in sub-Saharan Africa. It argues the position that cost-effectiveness analysis tends to exclude those with high cost-to-treat illness, and decisions made on that basis alone are not acceptable to the general population on whose behalf those decisions are made.

Single Ventricle Palliation in a Developing Sub-Saharan African Country: What Should be Improved?

Introduction:

Single ventricle physiology management is challenging, especially in low-income countries.

Objective:

To report the palliation outcomes of single ventricle patients in a developing African country.

Methods:

We retrospectively studied 83 consecutive patients subjected to single ventricle palliation in a single center between March 2011 and December 2017. Preoperative data, surgical factors, postoperative results, and survival outcomes were analyzed. The patients were divided by palliation stage: I (pulmonary artery banding [PAB] or Blalock–Taussig shunt [BTS]), II (Glenn procedure), or III (Fontan procedure).

Results:

Of the 83 patients who underwent palliation (stages I-III), 38 deaths were observed (31 after stage I, six after stage II, and one after stage III) for an overall mortality of 45.7%. The main causes of operative mortality were multiple organ dysfunction due to sepsis, shunt occlusion, and cardiogenic shock. Twenty-eight survivors were lost to follow-up (22 after stage I, six after stage II). Thirteen stage II survivors are still waiting for stage III. The mean follow-up was 366 ± 369 days. Five-year survival was 28.4 % for PAB and 30.1% for BTS, while that for stage II and III was 49.8% and 57.1%, respectively. Age (hazard ratio, 0.61; 95% confidence interval: 0.47-0.7; P = .000) and weight at surgery (hazard ratio, 0.45; 95% confidence interval: 0.31-0.64; P = .002) impacted survival.

Conclusion:

A high-mortality rate was observed in this initial experience, mainly in stage I patients. A large number of patients were lost to follow-up. A task force to improve outcomes is urgently required.

Genomics and Epigenomics of Congenital Heart Defects: Expert Review and Lessons Learned in Africa

Congenital heart defects (CHD) are structural malformations found at birth with a prevalence of 1%. The clinical trajectory of CHD is highly variable and thus in need of robust diagnostics and therapeutics. Major surgical interventions are often required for most CHDs. In Africa, despite advances in life sciences infrastructure and improving education of medical scholars, the limited clinical data suggest that CHD detection and correction are still not at par with the rest of the world. But the toll and genetics of CHDs in Africa has seldom been systematically investigated. We present an expert review on CHD with lessons learned on Africa. We found variable CHD phenotype prevalence in Africa across countries and populations. There are important gaps and paucity in genomic studies of CHD in African populations. Among the available genomic studies, the key findings in Africa were variants in GATA4 (P193H), MTHFR 677TT, and MTHFR 1298CC that were associated with atrial septal defect, ventricular septal defect (VSD), Tetralogy of Fallot (TOF), and patent ductus arteriosus phenotypes and 22q.11 deletion, which is associated with TOF. There were no data on epigenomic association of CHD in Africa, however, other studies have shown an altered expression of miR-421 and miR-1233-3p to be associated with TOF and hypermethylation of CpG islands in the promoter of SCO2 gene also been associated with TOF and VSD in children with non-syndromic CHD. These findings signal the urgent need to develop and implement genetic and genomic research on CHD to identify the hereditary and genome-environment interactions contributing to CHD. These projected studies would also offer comparisons on CHD pathophysiology between African and other populations worldwide. Genomic research on CHD in Africa should be developed in parallel with next generation technology policy research and responsible innovation frameworks that examine the social and political factors that shape the emergence and societal embedding of new technologies.