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Oyo-Ita A, Oduwole O, Arikpo D, Effa EE, Esu EB, Balakrishna Y, Chibuzor MT, Oringanje CM, Nwachukwu CE, Wiysonge CS, Meremikwu MM. Interventions for improving coverage of childhood immunisation in low- and middle-income countries. Cochrane Database Syst Rev 2023; 12:CD008145. [PMID: 38054505 PMCID: PMC10698843 DOI: 10.1002/14651858.cd008145.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Immunisation plays a major role in reducing childhood morbidity and mortality. Getting children immunised against potentially fatal and debilitating vaccine-preventable diseases remains a challenge despite the availability of efficacious vaccines, particularly in low- and middle-income countries. With the introduction of new vaccines, this becomes increasingly difficult. There is therefore a current need to synthesise the available evidence on the strategies used to bridge this gap. This is a second update of the Cochrane Review first published in 2011 and updated in 2016, and it focuses on interventions for improving childhood immunisation coverage in low- and middle-income countries. OBJECTIVES To evaluate the effectiveness of intervention strategies to boost demand and supply of childhood vaccines, and sustain high childhood immunisation coverage in low- and middle-income countries. SEARCH METHODS We searched CENTRAL, MEDLINE, CINAHL, and Global Index Medicus (11 July 2022). We searched Embase, LILACS, and Sociological Abstracts (2 September 2014). We searched WHO ICTRP and ClinicalTrials.gov (11 July 2022). In addition, we screened reference lists of relevant systematic reviews for potentially eligible studies, and carried out a citation search for 14 of the included studies (19 February 2020). SELECTION CRITERIA Eligible studies were randomised controlled trials (RCTs), non-randomised RCTs (nRCTs), controlled before-after studies, and interrupted time series conducted in low- and middle-income countries involving children that were under five years of age, caregivers, and healthcare providers. DATA COLLECTION AND ANALYSIS We independently screened the search output, reviewed full texts of potentially eligible articles, assessed the risk of bias, and extracted data in duplicate, resolving discrepancies by consensus. We conducted random-effects meta-analyses and used GRADE to assess the certainty of the evidence. MAIN RESULTS Forty-one studies involving 100,747 participants are included in the review. Twenty studies were cluster-randomised and 15 studies were individually randomised controlled trials. Six studies were quasi-randomised. The studies were conducted in four upper-middle-income countries (China, Georgia, Mexico, Guatemala), 11 lower-middle-income countries (Côte d'Ivoire, Ghana, Honduras, India, Indonesia, Kenya, Nigeria, Nepal, Nicaragua, Pakistan, Zimbabwe), and three lower-income countries (Afghanistan, Mali, Rwanda). The interventions evaluated in the studies were health education (seven studies), patient reminders (13 studies), digital register (two studies), household incentives (three studies), regular immunisation outreach sessions (two studies), home visits (one study), supportive supervision (two studies), integration of immunisation services with intermittent preventive treatment of malaria (one study), payment for performance (two studies), engagement of community leaders (one study), training on interpersonal communication skills (one study), and logistic support to health facilities (one study). We judged nine of the included studies to have low risk of bias; the risk of bias in eight studies was unclear and 24 studies had high risk of bias. We found low-certainty evidence that health education (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.15 to 1.62; 6 studies, 4375 participants) and home-based records (RR 1.36, 95% CI 1.06 to 1.75; 3 studies, 4019 participants) may improve coverage with DTP3/Penta 3 vaccine. Phone calls/short messages may have little or no effect on DTP3/Penta 3 vaccine uptake (RR 1.12, 95% CI 1.00 to 1.25; 6 studies, 3869 participants; low-certainty evidence); wearable reminders probably have little or no effect on DTP3/Penta 3 uptake (RR 1.02, 95% CI 0.97 to 1.07; 2 studies, 1567 participants; moderate-certainty evidence). Use of community leaders in combination with provider intervention probably increases the uptake of DTP3/Penta 3 vaccine (RR 1.37, 95% CI 1.11 to 1.69; 1 study, 2020 participants; moderate-certainty evidence). We are uncertain about the effect of immunisation outreach on DTP3/Penta 3 vaccine uptake in children under two years of age (RR 1.32, 95% CI 1.11 to 1.56; 1 study, 541 participants; very low-certainty evidence). We are also uncertain about the following interventions improving full vaccination of children under two years of age: training of health providers on interpersonal communication skills (RR 5.65, 95% CI 3.62 to 8.83; 1 study, 420 participants; very low-certainty evidence), and home visits (RR 1.29, 95% CI 1.15 to 1.45; 1 study, 419 participants; very low-certainty evidence). The same applies to the effect of training of health providers on interpersonal communication skills on the uptake of DTP3/Penta 3 by one year of age (very low-certainty evidence). The integration of immunisation with other services may, however, improve full vaccination (RR 1.29, 95% CI 1.16 to 1.44; 1 study, 1700 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Health education, home-based records, a combination of involvement of community leaders with health provider intervention, and integration of immunisation services may improve vaccine uptake. The certainty of the evidence for the included interventions ranged from moderate to very low. Low certainty of the evidence implies that the true effect of the interventions might be markedly different from the estimated effect. Further, more rigorous RCTs are, therefore, required to generate high-certainty evidence to inform policy and practice.
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Affiliation(s)
- Angela Oyo-Ita
- Department of Community Health, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Olabisi Oduwole
- Department of Medical Laboratory Science, Achievers University, Owo, Nigeria
| | - Dachi Arikpo
- Cochrane Nigeria, Institute of Tropical Diseases Research and Prevention, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Emmanuel E Effa
- Internal Medicine, College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Ekpereonne B Esu
- Department of Public Health, College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Yusentha Balakrishna
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa
| | - Moriam T Chibuzor
- Cochrane Nigeria, Institute of Tropical Diseases Research and Prevention, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Chioma M Oringanje
- GIDP Entomology and Insect Science, University of Tucson, Tucson, Arizona, USA
| | | | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Vaccine-Preventable Diseases Programme, World Health Organization Regional Office for Africa, Cité du Djoué, Brazzaville, Congo
| | - Martin M Meremikwu
- Department of Paediatrics, University of Calabar Teaching Hospital, Calabar, Nigeria
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Otu AA, Effa EE, Onwusaka O, Omoyele C, Arakelyan S, Okuzu O, Walley J. mHealth guideline training for non-communicable diseases in primary care facilities in Nigeria: a mixed methods pilot study. BMJ Open 2022; 12:e060304. [PMID: 36028271 PMCID: PMC9422821 DOI: 10.1136/bmjopen-2021-060304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To pilot the use of a scalable innovative mobile health (mHealth) non-communicable diseases (NCDs) training application for nurses at the primary care level. DESIGN Mixed methods pilot of mHealth training on NCD care for nurses at primary healthcare (PHC) facilities. We provide a descriptive analysis of mHealth training test scores, with trend analysis of blood pressure (BP) control using paired t-test for quantitative data and thematic analysis for qualitative data. SETTING PHC facilities in rural and urban communities in Cross River State, south eastern Nigeria. NCDs were not part of routine training previously. As in most low-and-middle-income settings, funding for scale-up using conventional classroom in-service training for NCDs is not available in Nigeria, and onsite supervision poses challenges. PARTICIPANTS Twenty-four health workers in 19 PHC facilities. INTERVENTION A self-paced mHealth training module on an NCD desk guide was adapted to be applicable within the Nigerian context in collaboration with the Federal Ministry of Health. The training which focused on hypertension, diabetes and sickle cell disease was delivered via Android tablet devices, supplemented by quarterly onsite supervision and group support via WhatsApp. The training was evaluated with pre/post-course tests, structured observations and focus group discussions. This was an implementation pilot assessing the feasibility and potential effectiveness of mHealth training on NCD in primary care delivery. RESULTS Nurses who received mHealth training recorded a statistically significant difference (p<0.001) in average pretest and post-test training scores of 65.2 (±12.2) and 86.5 (±7.9), respectively. Recordings on treatment cards indicated appropriate diagnosis and follow-up of patients with hypertension with significant improvements in systolic BP (t=5.09, p<0.001) and diastolic BP (t=5.07, p<0.001). The mHealth nurse training and WhatsApp support groups were perceived as valuable experiences and obviated the need for face-to-face training. Increased workload, non-availability of medications, facility-level conflicts and poor task shifting were identified challenges. CONCLUSIONS This initiative provides evidence of the feasibility of implementing an NCD care package supported by mHealth training for health workers in PHCs and the strong possibility of successful scale-up nationally.
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Affiliation(s)
- Akaninyene Asuquo Otu
- Department of Internal Medicine, College of Medical Sciences, University of Calabar, Calabar, Cross River State, Nigeria
- Foundation for Healthcare Innovation and Development, (FHIND), Calabar, Cross River State, Nigeria
| | - Emmanuel E Effa
- Department of Internal Medicine, College of Medical Sciences, University of Calabar, Calabar, Cross River State, Nigeria
- Foundation for Healthcare Innovation and Development, (FHIND), Calabar, Cross River State, Nigeria
| | - Obiageli Onwusaka
- Foundation for Healthcare Innovation and Development, (FHIND), Calabar, Cross River State, Nigeria
- Department of Public Health, Faculty of Allied Medical Sciences, College of Medical Sciences, C, University of Calabar, Calabar, Cross River State, Nigeria
| | | | - Stella Arakelyan
- Queen Margaret University Institute for International Health and Development, Edinburgh, Edinburgh, UK
| | - Okey Okuzu
- Instrat Global Health Solutions, Abuja, Nigeria
| | - John Walley
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, Leeds, UK
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Esu EB, Effa EE, Opie ON, Meremikwu MM. Artemether for severe malaria. Emergencias 2021; 32:131-132. [PMID: 32125113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Ekpereonne B Esu
- Department of Public Health, College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Emmanuel E Effa
- Internal Medicine, College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Oko N Opie
- Department of General Studies, Federal College of Education, Obudu, Nigeria
| | - Martin M Meremikwu
- Department of Paediatrics, University of Calabar Teaching Hospital, Calabar, Nigeria
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Karumbi J, Davids MR, Effa EE, Ben-Shlomo Y. Less intensive versus conventional haemodialysis for people with end-stage kidney disease. Hippokratia 2020. [DOI: 10.1002/14651858.cd013671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jamlick Karumbi
- East African Kidney Institute; Ministry of Health Kenya; Nairobi Kenya
| | - Mogamat Razeen Davids
- Division of Nephrology; Stellenbosch University and Tygerberg Hospital; Cape Town South Africa
| | - Emmanuel E Effa
- Internal Medicine; College of Medical Sciences, University of Calabar; Calabar Nigeria
| | - Yoav Ben-Shlomo
- Department of Population Health Sciences; University of Bristol; Bristol UK
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Ekrikpo UE, Mnika K, Effa EE, Ajayi SO, Okwuonu C, Waziri B, Bello A, Dandara C, Kengne AP, Wonkam A, Okpechi I. Association of Genetic Polymorphisms of TGF-β1, HMOX1, and APOL1 With CKD in Nigerian Patients With and Without HIV. Am J Kidney Dis 2020; 76:100-108. [PMID: 32354559 DOI: 10.1053/j.ajkd.2020.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 01/06/2020] [Indexed: 12/27/2022]
Abstract
RATIONALE & OBJECTIVE Recent studies in the human immunodeficiency virus (HIV)-infected population have suggested that there are genetic predispositions to the development of chronic kidney disease (CKD) in this context. We investigated the association of genetic polymorphisms of the genes encoding apolipoprotein L1 (APOL1), transforming growth factor β1 (TGF-β1; a profibrotic cytokine), and heme oxygenase 1 (HMOX1) with prevalent CKD among adults with and without HIV infection. STUDY DESIGN Case-control study. SETTING & PARTICIPANTS West African adults including 217 HIV-infected patients with CKD (HIV+/CKD+ group), 595 HIV-infected patients without CKD (HIV+/CKD- group), 269 with CKD and no HIV infection (HIV-/CKD+ group), and 114 with neither CKD nor HIV (HIV-/CKD- group). EXPOSURE The genetic polymorphisms with reference single-nucleotide polymorphism (rs) identification numbers rs1800469 (TGF-β1), rs1800470 (TGF-β1), rs121918282 (TGF-β1); rs60910145 (APOL1 G1 risk allele), rs73885319 (APOL1 G1 risk allele), rs71785313 (APOL1 G2 risk allele), and rs743811 (HMOX1); HIV. OUTCOME CKD. ANALYTICAL APPROACH Single-nucleotide polymorphism (SNP) genotyping of rs1800469 (TGF-β1), rs1800470 (TGF-β1), rs121918282 (TGF-β1); rs60910145 (APOL1), rs73885319 (APOL1), rs71785313 (APOL1), and rs743811 (HMOX1) was performed. Hardy-Weinberg equilibrium was evaluated for all SNPs, and minor allele frequencies were reported. A case-control analysis was performed, and multivariable logistic regression was used to control for potential confounders. RESULTS Minor allele frequencies for TGF-β1 (rs1800469, rs1800470, and rs1800471), APOL1 (rs60910145, rs73885319, and rs71785313), and HMOX1 (rs743811) were 0.25, 0.46, 0.46, 0.44, 0.45, 0.17, and 0.14, respectively. Among HIV-positive individuals, only TGF-β1 rs1800470 (GG vs AA), APOL1 (in the recessive model), and hypertension were associated with prevalent CKD (adjusted ORs of 0.44 [95% CI, 0.20-0.97], 2.54 [95% CI, 1.44-4.51], and 2.17 [95% CI, 1.35-3.48], respectively). No SNP polymorphisms were associated with prevalent CKD among HIV-negative individuals. LIMITATIONS The lack of histopathology data for proper categorization of the type of HIV-related nephropathy. CONCLUSIONS APOL1 polymorphisms were highly prevalent in this population and among adult patients infected with HIV and were associated with increased CKD risk. The TGF-β1 (rs1800470) polymorphism was associated with reduced risk, and HMOX1 polymorphisms were unassociated with CKD.
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Affiliation(s)
- Udeme E Ekrikpo
- Department of Medicine, University of Uyo, Uyo, Nigeria; Kidney & Hypertension Research Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Khuthala Mnika
- Division of Human Genetics, University of Cape Town, Cape Town, South Africa
| | - Emmanuel E Effa
- Department of Medicine, University of Calabar, Calabar, Nigeria
| | - Samuel O Ajayi
- Department of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Chimezie Okwuonu
- Department of Medicine, Federal Medical Centre, Umuahia, Nigeria
| | - Bala Waziri
- Department of Medicine, IBB Specialist Hospital, Minna, Nigeria
| | - Aminu Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Collet Dandara
- Division of Human Genetics, University of Cape Town, Cape Town, South Africa
| | - Andre P Kengne
- Non-communicable Disease Research Unit, Medical Research Council, Cape Town, South Africa
| | - Ambroise Wonkam
- Division of Human Genetics, University of Cape Town, Cape Town, South Africa.
| | - Ikechi Okpechi
- Kidney & Hypertension Research Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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Jones E, Rayner BL, Effa EE, Okpechi IG, Schmitz M, Heering PJ. Survey on available treatment for acute kidney injury in the Southern African Development Community and Nigeria: are we ready for zero deaths by 2025 in sub-Saharan Africa? BMJ Open 2019; 9:e029001. [PMID: 31462473 PMCID: PMC6720132 DOI: 10.1136/bmjopen-2019-029001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES The International Society of Nephrology (ISN) has called for zero deaths by 2025. This survey aimed to determine the preparedness of Southern African Development Community (SADC) countries and Nigeria to heed this call. SETTING A questionnaire was emailed to facilities, where renal replacement therapy is available; to determine type of services available; quality of care and identify clinicians involved. PARTICIPANTS Clinicians and administrators involved in the care of patients with acute kidney injury (AKI) completed the questionnaire. RESULTS Completed questionnaires were received from 12 of the 15 SADC countries and Nigeria, covering 48 service providers. The government provided partial funding for dialysis in 41.7% of services. There was no funding for acute dialysis in two countries. Interdisciplinary teams in 72.9% of hospitals covered the intensive care units (ICUs), which included at least one nephrologist in 75%. Only 77% were able to provide dialysis in ICU. Intermittent haemodialysis was the most common modality available (91.7% of facilities), sustained low-efficiency dialysis in 50%, continuous therapies in 35% and peritoneal dialysis in 33.3%. Almost half (47.9%) of the sites were limited to one mode of dialysis and unable to care for severely ill patients. The clinical status was used to initiate and monitor dialysis, with very few sites having clear written standard operating procedures. CONCLUSION In the 16 countries surveyed, the majority had limited ability to provide comprehensive dialysis programmes for patients with AKI due to lack of facilities and government funding. Additionally, nephrologists are scarce; modes of dialysis are limited; as is the care for severely ill patients and lack of standard operating procedures. Resources, training and funding need to be made available to create universal coverage of dialysis for AKI. The ISN goal of providing renal replacement therapy to all by 2025 is unlikely to be achieved in SADC and Nigeria.
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Affiliation(s)
- Erika Jones
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Brian L Rayner
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Emmanuel E Effa
- Department of Internal Medicine, University of Calabar, Calabar, Nigeria
| | - Ikechi G Okpechi
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Michael Schmitz
- Nephrology, Heinrich Heine University of Düsseldorf, Solingen, Germany
- Solingen General Hospital, Solingen, Germany
| | - Peter J Heering
- Nephrology, Heinrich Heine University of Düsseldorf, Solingen, Germany
- Solingen General Hospital, Solingen, Germany
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Effa EE, Oduwole O, Schoonees A, Hohlfeld A, Durao S, Kredo T, Mbuagbaw L, Meremikwu M, Ongolo-Zogo P, Wiysonge C, Young T. Priority setting for new systematic reviews: processes and lessons learned in three regions in Africa. BMJ Glob Health 2019; 4:e001615. [PMID: 31406592 PMCID: PMC6666801 DOI: 10.1136/bmjgh-2019-001615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/10/2019] [Accepted: 06/29/2019] [Indexed: 12/22/2022] Open
Abstract
Priority setting to identify topical and context relevant questions for systematic reviews involves an explicit, iterative and inclusive process. In resource-constrained settings of low-income and middle-income countries, priority setting for health related research activities ensures efficient use of resources. In this paper, we critically reflect on the approaches and specific processes adopted across three regions of Africa, present some of the outcomes and share the lessons learnt while carrying out these activities. Priority setting for new systematic reviews was conducted between 2016 and 2018 across three regions in Africa. Different approaches were used: Multimodal approach (Central Africa), Modified Delphi approach (West Africa) and Multilevel stakeholder discussion (Southern-Eastern Africa). Several questions that can feed into systematic reviews have emerged from these activities. We have learnt that collaborative subregional efforts using an integrative approach can effectively lead to the identification of region specific priorities. Systematic review workshops including discussion about the role and value of reviews to inform policy and research agendas were a useful part of the engagements. This may also enable relevant stakeholders to contribute towards the priority setting process in meaningful ways. However, certain shared challenges were identified, including that emerging priorities may be overlooked due to differences in burden of disease data and differences in language can hinder effective participation by stakeholders. We found that face-to-face contact is crucial for success and follow-up engagement with stakeholders is critical in driving acceptance of the findings and planning future progress.
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Affiliation(s)
- Emmanuel E Effa
- Internal Medicine, Faculty of Medicine, University of Calabar, Calabar, Nigeria
| | - Olabisi Oduwole
- Cochrane Nigeria, Calabar Institute of Tropical Disease Research and Prevention, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Anel Schoonees
- Centre for Evidence-based Health Care, Department of Global Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Ameer Hohlfeld
- Cochrane South Africa, Medical Research Council of South Africa, Tygerberg, South Africa
| | - Solange Durao
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Pierre Ongolo-Zogo
- Centre for Development of Best Practices in Health, Central Hospital of Yaounde, Yaounde, Cameroon
| | - Charles Wiysonge
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Taryn Young
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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Abstract
BACKGROUND In 2011 the World Health Organization (WHO) recommended parenteral artesunate in preference to quinine as first-line treatment for people with severe malaria. Prior to this recommendation many countries, particularly in Africa, had begun to use artemether, an alternative artemisinin derivative. This Cochrane Review evaluates intramuscular artemether compared with both quinine and artesunate. OBJECTIVES To assess the efficacy and safety of intramuscular artemether versus any other parenteral medication in the treatment of severe malaria in adults and children. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, and LILACS, ISI Web of Science, conference proceedings, and reference lists of articles. We also searched the WHO International Clinical Trial Registry Platform, ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) for ongoing trials up to 7 September 2018. We checked the reference lists of all studies identified by the search. We examined references listed in review articles and previously compiled bibliographies to look for eligible studies. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing intramuscular artemether with intravenous/intramuscular quinine or artesunate for treating severe malaria. DATA COLLECTION AND ANALYSIS The primary outcome was all-cause death. Two review authors independently screened each article by title and abstract, and examined potentially relevant studies for inclusion using an eligibility form. Two review authors independently extracted data and assessed risk of bias of included studies. We summarized dichotomous outcomes using risk ratios (RRs) and continuous outcomes using mean differences (MDs), and have presented both measures with 95% confidence intervals (CIs). Where appropriate, we combined data in meta-analyses and used the GRADE approach to summarize the certainty of the evidence. MAIN RESULTS We included 19 RCTs, enrolling 2874 adults and children with severe malaria, carried out in Africa (12 trials) and in Asia (7 trials).Artemether versus quinineFor children, there is probably little or no difference in the risk of death between intramuscular artemether and quinine (RR 0.97, 95% CI 0.77 to 1.21; 13 trials, 1659 participants, moderate-certainty evidence). Coma resolution time may be about five hours shorter with artemether (MD -5.45, 95% CI -7.90 to -3.00; six trials, 358 participants, low-certainty evidence). Artemether may make little difference to neurological sequelae (RR 0.84, 95% CI 0.66 to 1.07; seven trials, 968 participants, low-certainty evidence). Compared to quinine, artemether probably shortens the parasite clearance time by about nine hours (MD -9.03, 95% CI -11.43 to -6.63; seven trials, 420 participants, moderate-certainty evidence), and may shorten the fever clearance time by about three hours (MD -3.73, 95% CI -6.55 to -0.92; eight trials, 457 participants, low-certainty evidence).For adults, treatment with intramuscular artemether probably results in fewer deaths than treatment with quinine (RR 0.59, 95% CI 0.42 to 0.83; four trials, 716 participants, moderate-certainty evidence).Artemether versus artesunateArtemether and artesunate have not been directly compared in randomized trials in children.For adults, mortality is probably higher with intramuscular artemether (RR 1.80, 95% CI 1.09 to 2.97; two trials, 494 participants, moderate-certainty evidence). AUTHORS' CONCLUSIONS Artemether appears to be more effective than quinine in children and adults. Artemether compared to artesunate has not been extensively studied, but in adults it appears inferior. These findings are consistent with the WHO recommendations that artesunate is the drug of choice, but artemether is acceptable when artesunate is not available.
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Affiliation(s)
- Ekpereonne B Esu
- College of Medical Sciences, University of CalabarDepartment of Public HealthCalabarCross River StateNigeria
| | - Emmanuel E Effa
- College of Medical Sciences, University of CalabarInternal MedicinePMB 1115CalabarCross River StateNigeria540001
| | - Oko N Opie
- Federal College of EducationDepartment of General StudiesObuduCross River StateNigeria
| | - Martin M Meremikwu
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarCross River StateNigeria
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Ekrikpo UE, Kengne AP, Bello AK, Effa EE, Noubiap JJ, Salako BL, Rayner BL, Remuzzi G, Okpechi IG. Chronic kidney disease in the global adult HIV-infected population: A systematic review and meta-analysis. PLoS One 2018; 13:e0195443. [PMID: 29659605 PMCID: PMC5901989 DOI: 10.1371/journal.pone.0195443] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 03/22/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The widespread use of antiretroviral therapies (ART) has increased life expectancy in HIV patients, predisposing them to chronic non-communicable diseases including Chronic Kidney Disease (CKD). We performed a systematic review and meta-analysis (PROSPERO registration number CRD42016036246) to determine the global and regional prevalence of CKD in HIV patients. METHODS We searched PubMed, Web of Science, EBSCO and AJOL for articles published between January 1982 and May 2016. CKD was defined as estimated glomerular filtration rate (eGFR) <60ml/min using the MDRD, Cockcroft-Gault or CKD-EPI equations. Random effects model was used to combine prevalence estimates from across studies after variance stabilization via Freeman-Tukey transformation. RESULT Sixty-one eligible articles (n = 209,078 HIV patients) in 60 countries were selected. The overall CKD prevalence was 6.4% (95%CI 5.2-7.7%) with MDRD, 4.8% (95%CI 2.9-7.1%) with CKD-EPI and 12.3% (95%CI 8.4-16.7%) with Cockcroft-Gault; p = 0.003 for difference across estimators. Sub-group analysis identified differences in prevalence by WHO region with Africa having the highest MDRD-based prevalence at 7.9% (95%CI 5.2-11.1%). Within Africa, the pooled MDRD-based prevalence was highest in West Africa [14.6% (95%CI 9.9-20.0%)] and lowest in Southern Africa (3.2%, 95%CI 3.0-3.4%). The heterogeneity observed could be explained by WHO region, comorbid hypertension and diabetes mellitus, but not by gender, hepatitis B or C coinfection, CD4 count or antiretroviral status. CONCLUSION CKD is common in HIV-infected people, particularly in Africa. HIV treatment programs need to intensify screening for CKD with added need to introduce global guidelines for CKD identification and treatment in HIV positive patients.
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Affiliation(s)
- Udeme E. Ekrikpo
- Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Renal Unit, Department of Medicine, University of Uyo, Uyo, Nigeria
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Andre P. Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, Cape Town, South Africa
| | - Aminu K. Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Emmanuel E. Effa
- Renal Unit, Department of Medicine, University of Calabar, Calabar, Nigeria
| | - Jean Jacques Noubiap
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Babatunde L. Salako
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Brian L. Rayner
- Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Giuseppe Remuzzi
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases Aldo & Cele Daccò, Bergamo, Italy
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
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Ekrikpo UE, Kengne AP, Akpan EE, Effa EE, Bello AK, Ekott JU, George C, Salako BL, Okpechi IG. Prevalence and correlates of chronic kidney disease (CKD) among ART-naive HIV patients in the Niger-Delta region of Nigeria. Medicine (Baltimore) 2018; 97:e0380. [PMID: 29668591 PMCID: PMC5916672 DOI: 10.1097/md.0000000000010380] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Widespread use of antiretroviral therapy (ART) in human immunodeficiency virus (HIV) patients has led to improved longevity with the attendant increase in noncommunicable disease prevalence including chronic kidney disease (CKD). This study documents the prevalence of CKD in a large HIV population in Southern Nigeria.This is a single center, 15-year analysis in ART-naïve patients. CKD was defined as the occurrence of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m on 2 consecutive occasions 3 to 12 months apart using the chronic kidney disease epidemiology collaboration (CKD-EPI) equation. The Cochran-Armitage and Cuzick tests were employed to assess for trend across the years for CKD prevalence and CD4 count, respectively. Multivariable logistic regression models were used to identify independent associations with CKD.In all, 1317 patients (62.2% females) with mean age of 34.5 years and median CD4 count of 194 cells/μL were included. CKD prevalence was 13.4% (95%CI 11.6%-15.4%) using the CKD-EPI equation (without the race factor). Multivariable analysis identified increasing age and CD4 count <200 cells/μL as being independently associated with CKD occurrence.This study reports a high prevalence of CKD in ART-naïve HIV-infected patients. Measures to improve diagnosis of kidney disease and ensure early initiation of treatment should be integrated in HIV treatment programmes in this setting.
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Affiliation(s)
- Udeme E. Ekrikpo
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Uyo, Uyo, Nigeria
| | - Andre P. Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, Cape Town, South Africa
| | | | | | - Aminu K. Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - John U. Ekott
- Department of Medicine, University of Uyo, Uyo, Nigeria
| | - Cindy George
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, Cape Town, South Africa
| | - Babatunde L. Salako
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
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Akudo Nwagbara B, Effa EE, Abubakar D, Osagie OE. Interventions to improve vaginal health for reducing the risk of HIV acquisition. Hippokratia 2017. [DOI: 10.1002/14651858.cd009869.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Emmanuel E Effa
- College of Medical Sciences, University of Calabar; Internal Medicine; PMB 1115 Calabar Cross River State Nigeria 540001
| | - Danladi Abubakar
- Federal Medical Center; Obstetrics and Gynaecology; Gusau Zamfara State Nigeria
| | - Osayande E Osagie
- University of Melbourne; School of Public Health; Melbourne Victoria Australia
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Effa EE, Okpa HO, Arije A, Salako BL, Kadiri S. A non-functioning left kidney from renal tuberculosis: A case report. Niger J Med 2017. [DOI: 10.4103/1115-2613.302795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
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13
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Okonkwo RI, Weidmann AE, Effa EE. Erratum to: Renal and Bone Adverse Effects of a Tenofovir-Based Regimen in the Treatment of HIV-Infected Children: A Systematic Review. Drug Saf 2016; 39:369. [PMID: 26895340 DOI: 10.1007/s40264-016-0396-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Rose I Okonkwo
- Principal Health Consulting Limited, Benin City, Edo State, Nigeria.
| | - Anita E Weidmann
- School of Pharmacy, Faculty of Health and Social Care, Robert Gordon University, Aberdeen, UK
| | - Emmanuel E Effa
- Internal Medicine, Faculty of Medicine and Dentistry, University of Calabar, Calabar, Cross River State, Nigeria
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Abstract
BACKGROUND A septic abortion refers to any abortion (spontaneous or induced) complicated by upper genital tract infection including endometritis or parametritis. The mainstay of treatment of septic abortion is antibiotic therapy alone or in combination with evacuation of retained products of conception. Regimens including broad-spectrum antibiotics are routinely recommended for treatment. However, there is no consensus on the most effective antibiotics alone or in combination to treat septic abortion. This review aimed to bridge this gap in knowledge to inform policy and practice. OBJECTIVES To review the effectiveness of various individual antibiotics or antibiotic regimens in the treatment of septic abortion. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and POPLINE using the following keywords: 'Abortion', 'septic abortion', 'Antibiotics', 'Infected abortion', 'postabortion infection'. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials on 19 April, 2016. SELECTION CRITERIA We considered for inclusion randomised controlled trials (RCTs) and non-RCTs that compared antibiotic(s) to another antibiotic(s), irrespective of route of administration, dosage, and duration as well as studies comparing antibiotics alone with antibiotics in combination with other interventions such as dilation and curettage (D&C). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from included trials. We resolved disagreements through consultation with a third author. One review author entered extracted data into Review Manager 5.3, and a second review author cross-checked the entry for accuracy. MAIN RESULTS We included 3 small RCTs involving 233 women that were conducted over 3 decades ago.Clindamycin did not differ significantly from penicillin plus chloramphenicol in reducing fever in all women (mean difference (MD) -12.30, 95% confidence interval (CI) -25.12 to 0.52; women = 77; studies = 1). The evidence for this was of moderate quality. "Response to treatment was evaluated by the patient's 'fever index' expressed in degree-hour and defined as the total quantity of fever under the daily temperature curve with 99°F (37.2°C) as the baseline".There was no difference in duration of hospitalisation between clindamycin and penicillin plus chloramphenicol. The mean duration of hospital stay for women in each group was 5 days (MD 0.00, 95% CI -0.54 to 0.54; women = 77; studies = 1).One study evaluated the effect of penicillin plus chloramphenicol versus cephalothin plus kanamycin before and after D&C. Response to therapy was evaluated by "the time from start of antibiotics until fever lysis and time from D&C until patients become afebrile". Low-quality evidence suggested that the effect of penicillin plus chloramphenicol on fever did not differ from that of cephalothin plus kanamycin (MD -2.30, 95% CI -17.31 to 12.71; women = 56; studies = 1). There was no significant difference between penicillin plus chloramphenicol versus cephalothin plus kanamycin when D&C was performed during antibiotic therapy (MD -1.00, 95% CI -13.84 to 11.84; women = 56; studies = 1). The quality of evidence was low.A study with unclear risk of bias showed that the time for fever resolution (MD -5.03, 95% CI -5.77 to -4.29; women = 100; studies = 1) as well as time for resolution of leukocytosis (MD -4.88, 95% CI -5.98 to -3.78; women = 100; studies = 1) was significantly lower with tetracycline plus enzymes compared with intravenous penicillin G.Treatment failure and adverse events occurred infrequently, and the difference between groups was not statistically significant. AUTHORS' CONCLUSIONS We found no strong evidence that intravenous clindamycin alone was better than penicillin plus chloramphenicol for treating women with septic abortion. Similarly, available evidence did not suggest that penicillin plus chloramphenicol was better than cephalothin plus kanamycin for the treatment of women with septic abortion. Tetracyline enzyme antibiotic appeared to be more effective than intravenous penicillin G in reducing the time to fever defervescence, but this evidence was provided by only one study at low risk of bias.There is a need for high-quality RCTs providing reliable evidence for treatments of septic abortion with antibiotics that are currently in use. The three included studies were carried out over 30 years ago. There is also a need to include institutions in low-resource settings, such as sub-Saharan Africa, Latin America and the Caribbean, and South Asia, with a high burden of abortion and health systems challenges.
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Affiliation(s)
- Atim Udoh
- College of Medical Sciences, University of CalabarObstetrics and GynaecologyCalabarCross River StateNigeria
| | - Emmanuel E Effa
- College of Medical Sciences, University of CalabarInternal MedicinePMB 1115CalabarCross River StateNigeria540001
| | - Olabisi Oduwole
- University of Calabar Teaching Hospital (ITDR/P)Institute of Tropical Diseases Research and PreventionMoore RoadCalabarCross River StateNigeria
| | - Babasola O Okusanya
- Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi‐ArabaExperimental and Maternal Medicine Unit, Department of Obstetrics and GynaecologyLagosNigeria
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Affiliation(s)
- Bappa Adamu
- Aminu Kano Teaching Hospital; Department of Medicine; No 1 Hospital Road Kano Kano Nigeria PMB 3452
| | - Sani Usman Alhassan
- Bayero University Kano; Department of Surgery; 1 Hospital Rd Kano Nigeria PMB 3452
| | - Emmanuel E Effa
- College of Medical Sciences, University of Calabar; Internal Medicine; PMB 1115 Calabar Cross River State Nigeria 540001
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16
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Abstract
BACKGROUND In 2011 the World Health Organization (WHO) recommended parenteral artesunate in preference to quinine as first-line treatment for people with severe malaria. Prior to this recommendation, many countries, particularly in Africa, had begun to use artemether, an alternative artemisinin derivative. This review evaluates intramuscular artemether compared with both quinine and artesunate. OBJECTIVES To assess the efficacy and safety of intramuscular artemether versus any other parenteral medication in treating severe malaria in adults and children. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE and LILACS, ISI Web of Science, conference proceedings and reference lists of articles. We also searched the WHO clinical trial registry platform, ClinicalTrials.gov and the metaRegister of Controlled Trials (mRCT) for ongoing trials up to 9 April 2014. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing intramuscular artemether with intravenous or intramuscular antimalarial for treating severe malaria. DATA COLLECTION AND ANALYSIS The primary outcome was all-cause death.Two authors independently assessed trial eligibility, risk of bias and extracted data. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD), and presented both measures with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 18 RCTs, enrolling 2662 adults and children with severe malaria, carried out in Africa (11) and in Asia (7). Artemether versus quinine For children in Africa, there is probably little or no difference in the risk of death between intramuscular artemether and quinine (RR 0.96, 95% CI 0.76 to 1.20; 12 trials, 1447 participants, moderate quality evidence). Coma recovery may be about five hours shorter with artemether (MD -5.45, 95% CI -7.90 to -3.00; six trials, 358 participants, low quality evidence), and artemether may result in fewer neurological sequelae, but larger trials would be needed to confirm this (RR 0.84, 95% CI 0.66 to 1.07; seven trials, 968 participants, low quality evidence). Artemether probably shortens the parasite clearance time by about nine hours (MD -9.03, 95% CI -11.43 to -6.63; seven trials, 420 participants, moderate quality evidence), and may shorten the fever clearance time by about three hours (MD -3.73, 95% CI -6.55 to -0.92; eight trials, 457 participants, low quality evidence).For adults in Asia, treatment with intramuscular artemether probably results in fewer deaths than treatment with quinine (RR 0.59, 95% CI 0.42 to 0.83; four trials, 716 participants, moderate quality evidence). Artemether versus artesunate Artemether and artesunate have not been directly compared in randomized trials in African children.For adults in Asia, mortality is probably higher with intramuscular artemether (RR 1.80, 95% CI 1.09 to 2.97, two trials,494 participants, moderate quality evidence). AUTHORS' CONCLUSIONS Although there is a lack of direct evidence comparing artemether with artesunate, artemether is probably less effective than artesunate at preventing deaths from severe malaria. In circumstances where artesunate is not available, artemether is an alternative to quinine.
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Affiliation(s)
- Ekpereonne Esu
- University of CalabarDepartment of Public HealthCalabarNigeria540271
| | - Emmanuel E Effa
- College of Medical Sciences, University of CalabarInternal MedicinePMB 1115CalabarNigeria540001
| | - Oko N Opie
- Federal College of EducationDepartment of General StudiesObuduNigeria
| | - Amirahobu Uwaoma
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarCross River StateNigeria
| | - Martin M Meremikwu
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarNigeria
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17
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Abstract
Background The use of an effective contraceptive may be necessary after an abortion. Insertion of an intrauterine device (IUD) may be done the same day or later. Immediate IUD insertion is an option since the woman is not pregnant, pain of insertion is less because the cervical os is open, and her motivation to use contraception may be high. However, insertion of an IUD immediately after a pregnancy ends carries risks, such as spontaneous expulsion.Objectives To assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion.Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov,and ICTRP in January 27, 2014. We also contacted investigators to identify other trials.Selection criteria We sought all randomised controlled trials (RCTs) with at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion.Data collection and analysis We evaluated the methodological quality of each report and abstracted the data. We focused on discontinuation rates for accidental pregnancy, perforation, expulsion, and pelvic inflammatory disease.We computed the weighted average of the rate ratios.We compute drisk ratios (RRs) with 95% Confidence Intervals (CIs).We performed an intention-to-treat (ITT) analysis by including all randomised participants in the analysis according to the Cochrane Handbook for Systematic Reviews of Interventions.Main results We identified 12 trials most of which are of moderate risk of bias involving 7,119 participants which described random assignment.Five trials randomised to either immediate or delayed insertion of IUD. One of them randomised to immediate versus delayed insertion of Copper 7 showed immediate insertion of the Copper 7 was associated with a higher risk of expulsion than was delayed insertion(RR 11.98, 95% CI 1.61 to 89.35,1 study, 259 participants); the quality of evidence was moderate. Moderate quality of evidence also suggests that use and expulsion of levonorgestrel-releasing intrauterine system or CuT380A was more likely for immediate compared to delayed insertion risk ratio (RR) 1.40 (95% CI 1.24 to 1.58; 3 studies; 878 participants) and RR 2.64 ( 95% CI 1.16 to 6.00; 3 studies; 878 participants) respectively. Another trial randomised to the levonorgestrel IUD or Nova T showed discontinuation rates due to pregnancy were likely to be higher for women in the Nova T group. (MD 8.70, 95% CI 3.92 to 13.48;1 study; 438 participants);moderate quality evidence.Seven trials examined immediate insertion of IUD only. From meta-analysis of two multicentre trials, pregnancy was less likely for the TCu 220C versus the Lippes Loop (RR 0.43, 95% CI 0.24 to 0.75; 2 studies; 2257 participants ) as was expulsion (RR 0.61, 95% CI0.46 to 0.81; 2 studies; 2257 participants). Estimates for the TCu 220 versus the Copper 7 were RR 0.42 ( 95% CI 0.23 to 0.77; 2 studies, 2,274 participants) and RR 0.68, (95% CI 0.51 to 0.91); 2 studies, 2,274 participants), respectively. In other work, adding copper sleeves to the Lippes Loop improved efficacy (RR 3.40, 95% CI 1.28 to 9.04, 1 study, 400 participants) and reduced expulsion(RR 3.00, 95% CI 1.51 to 5.97; 1 study, 400 participants).Authors' conclusions Moderate quality evidence shows that insertion of an IUD immediately after abortion is safe and practical. IUD expulsion rates appear higher immediately after abortions compared to delayed insertions. However, at six months postabortion, IUD use is higher following immediate insertion compared to delayed insertion.
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Affiliation(s)
- Babasola O Okusanya
- Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi‐ArabaExperimental and Maternal Medicine Unit, Department of Obstetrics and GynaecologyLagosNigeria
| | - Olabisi Oduwole
- University of Calabar Teaching Hospital (ITDR/P)Institute of Tropical Diseases Research and PreventionMoore RoadCalabarCross River StateNigeria
| | - Emmanuel E Effa
- College of Medical Sciences, University of CalabarInternal MedicinePMB 1115CalabarCross River StateNigeria540001
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18
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Abstract
BACKGROUND Review status: Current question - no update intended. Azithromycin treatments are included in the review: Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). (Thaver D, Zaidi AKM, Critchley JA, Azmatullah A, Madni SA, Bhutta ZA. Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004530. DOI: 10.1002/14651858.CD004530.pub3.) This latter review is being updated, and will be published in late 2011.Enteric fever (typhoid and paratyphoid fever) is potentially fatal. Infection with drug-resistant strains of the causative organism Salmonella enterica serovar Typhi or Paratyphi increases morbidity and mortality. Azithromycin may have better outcomes in people with uncomplicated forms of the disease. OBJECTIVES To compare azithromycin with other antibiotics for treating uncomplicated enteric fever. SEARCH STRATEGY In August 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also searched conference proceedings, reference lists, and contacted researchers and a pharmaceutical company. SELECTION CRITERIA Randomized controlled trials comparing azithromycin with other antibiotics for treating children and adults with uncomplicated enteric fever confirmed by cultures of S. Typhi or Paratyphi in blood and/or stool. DATA COLLECTION AND ANALYSIS Both authors independently extracted data and assessed the risk of bias. Dichotomous data were presented and compared using the odds ratio, and continuous data were reported as arithmetic means with standard deviations and were combined using the mean difference (MD). Both were presented with 95% confidence intervals (CI). MAIN RESULTS Seven trials involving 773 participants met the inclusion criteria. The trials used adequate methods to generate the allocation sequence and conceal allocation, and were open label. Three trials exclusively included adults, two included children, and two included both adults and children; all were hospital inpatients. One trial evaluated azithromycin against chloramphenicol and did not demonstrate a difference for any outcome (77 participants, 1 trial). When compared with fluoroquinolones in four trials, azithromycin significantly reduced clinical failure (OR 0.48, 95% CI 0.26 to 0.89; 564 participants, 4 trials) and duration of hospital stay (MD -1.04 days, 95% CI -1.73 to -0.34 days; 213 participants, 2 trials); all four trials included people with multiple-drug-resistant or nalidixic acid-resistant strains of S. Typhi or S. Paratyphi. We detected no statistically significant difference in the other outcomes. Compared with ceftriaxone, azithromycin significantly reduced relapse (OR 0.09, 95% CI 0.01 to 0.70; 132 participants, 2 trials) and not other outcome measures. Few adverse events were reported, and most were mild and self limiting. AUTHORS' CONCLUSIONS Azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains. Azithromycin may perform better than ceftriaxone.
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Affiliation(s)
- Emmanuel E Effa
- University of Calabar Teaching HospitalInternal MedicinePMB 1278CalabarCross River StateNigeria
| | - Hasifa Bukirwa
- Makerere University Medical SchoolMulago Hospital ComplexPO Box 24943KampalaUganda
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19
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Abstract
BACKGROUND Typhoid and paratyphoid are febrile illnesses, due to a bacterial infection, which remain common in many low- and middle-income countries. The World Health Organization (WHO) currently recommends the fluoroquinolone antibiotics in areas with known resistance to the older first-line antibiotics. OBJECTIVES To evaluate fluoroquinolone antibiotics for treating children and adults with enteric fever. SEARCH STRATEGY We searched The Cochrane Infectious Disease Group Specialized Register (February 2011); Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library (2011, Issue 2); MEDLINE (1966 to February 2011); EMBASE (1974 to February 2011); and LILACS (1982 to February 2011). We also searched the metaRegister of Controlled Trials (mRCT) in February 2011. SELECTION CRITERIA Randomized controlled trials examining fluoroquinolone antibiotics, in people with blood, stool or bone marrow culture-confirmed enteric fever. DATA COLLECTION AND ANALYSIS Two authors independently assessed the trial's methodological quality and extracted data. We calculated risk ratios (RR) for dichotomous data and mean difference for continuous data with 95% confidence intervals (CI).Comparative effectiveness has been interpreted in the context of; length of treatment, dose, year of study, known levels of antibiotic resistance, or proxy measures of resistance such as the failure rate in the comparator arm. MAIN RESULTS Twenty-six studies, involving 3033 patients, are included in this review.Fluoroquinolones versus older antibiotics (chloramphenicol, co-trimoxazole, amoxicillin and ampicillin)In one study from Pakistan in 2003-04, high clinical failure rates were seen with both chloramphenicol and co-trimoxazole, although resistance was not confirmed microbiologically. A seven-day course of either ciprofloxacin or ofloxacin were found to be superior. Older studies of these comparisons failed to show a difference (six trials, 361 participants).In small studies conducted almost two decades ago, the fluoroquinolones were demonstrated to have fewer clinical failures than ampicillin and amoxicillin (two trials, 90 participants, RR 0.11, 95% CI 0.02 to 0.57).Fluoroquinolones versus current second-line options (ceftriaxone, cefalexin, and azithromycin)The two studies comparing a seven day course of oral fluoroquinolones with three days of intravenous ceftriaxone were too small to detect important differences between antibiotics should they exist (two trials, 89 participants).In Pakistan in 2003-04, no clinical or microbiological failures were seen with seven days of either ciprofloxacin, ofloxacin or cefixime (one trial, 139 participants). In Nepal in 2005, gatifloxacin reduced clinical failure and relapse compared to cefixime, despite a high prevalence of NaR in the study population (one trial, 158 participants, RR 0.04, 95% CI 0.01 to 0.31).Compared to a seven day course of azithromycin, a seven day course of ofloxacin had a higher rate of clinical failures in populations with both multi-drug resistance (MDR) and nalidixic acid resistance (NaR) enteric fever in Vietnam in 1998-2002 (two trials, 213 participants, RR 2.20, 95% CI 1.23 to 3.94). However, a more recent study from Vietnam in 2004-05, detected no difference between gatifloxacin and azithromycin with both drugs performing well (one trial, 287 participants). AUTHORS' CONCLUSIONS Generally, fluoroquinolones performed well in treating typhoid, and maybe superior to alternatives in some settings. However, we were unable to draw firm general conclusions on comparative contemporary effectiveness given that resistance changes over time, and many studies were small. Policy makers and clinicians need to consider local resistance patterns in choosing a fluoroquinolone or alternative.There is some evidence that the newest fluoroquinolone, gatifloxacin, remains effective in some regions where resistance to older fluoroquinolones has developed. However, the different fluoroquinolones have not been compared directly in trials in these settings.
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Affiliation(s)
- Emmanuel E Effa
- University of Calabar Teaching HospitalInternal MedicinePMB 1278CalabarNigeria
| | - Zohra S Lassi
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiPakistan74800
| | - Julia A Critchley
- Newcastle UniversityInstitute of Health and SocietyWilliam Leech BuildingThe Medical SchoolNewcastleUKNE2 4HH
| | - Paul Garner
- Liverpool School of Tropical MedicineInternational Health GroupPembroke PlaceLiverpoolUKL3 5QA
| | - David Sinclair
- Liverpool School of Tropical MedicineInternational Health GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Piero L Olliaro
- World Health OrganizationUNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR)1211 Geneva 27GenevaSwitzerland
| | - Zulfiqar A Bhutta
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiPakistan74800
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20
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Abstract
BACKGROUND Enteric fever (typhoid and paratyphoid fever) is potentially fatal. Infection with drug-resistant strains of the causative organism Salmonella enterica serovar Typhi or Paratyphi increases morbidity and mortality. Azithromycin may have better outcomes in people with uncomplicated forms of the disease. OBJECTIVES To compare azithromycin with other antibiotics for treating uncomplicated enteric fever. SEARCH STRATEGY In August 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also searched conference proceedings, reference lists, and contacted researchers and a pharmaceutical company. SELECTION CRITERIA Randomized controlled trials comparing azithromycin with other antibiotics for treating children and adults with uncomplicated enteric fever confirmed by cultures of S. Typhi or Paratyphi in blood and/or stool. DATA COLLECTION AND ANALYSIS Both authors independently extracted data and assessed the risk of bias. Dichotomous data were presented and compared using the odds ratio, and continuous data were reported as arithmetic means with standard deviations and were combined using the mean difference (MD). Both were presented with 95% confidence intervals (CI). MAIN RESULTS Seven trials involving 773 participants met the inclusion criteria. The trials used adequate methods to generate the allocation sequence and conceal allocation, and were open label. Three trials exclusively included adults, two included children, and two included both adults and children; all were hospital inpatients. One trial evaluated azithromycin against chloramphenicol and did not demonstrate a difference for any outcome (77 participants, 1 trial). When compared with fluoroquinolones in four trials, azithromycin significantly reduced clinical failure (OR 0.48, 95% CI 0.26 to 0.89; 564 participants, 4 trials) and duration of hospital stay (MD -1.04 days, 95% CI -1.73 to -0.34 days; 213 participants, 2 trials); all four trials included people with multiple-drug-resistant or nalidixic acid-resistant strains of S. Typhi or S. Paratyphi. We detected no statistically significant difference in the other outcomes. Compared with ceftriaxone, azithromycin significantly reduced relapse (OR 0.09, 95% CI 0.01 to 0.70; 132 participants, 2 trials) and not other outcome measures. Few adverse events were reported, and most were mild and self limiting. AUTHORS' CONCLUSIONS Azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains. Azithromycin may perform better than ceftriaxone.
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Affiliation(s)
- Emmanuel E Effa
- Internal Medicine, University of Calabar Teaching Hospital, PMB 1278, Calabar, Cross River State, Nigeria.
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