Facilitators and barriers to implementing chest radiography in tuberculosis systematic screening of clinically high-risk groups in Ethiopia: A qualitative study

Background

Chest X-ray has been included in national tuberculosis screening algorithms as a sensitive tuberculosis screening tool among high-risk groups. However, the implementation was influenced by multiple factors. We aimed to explore facilitators and barriers to implementing chest X-ray in systematic tuberculosis screening of clinically high-risk groups in Addis Ababa, Ethiopia.

Methods

We conducted face-to-face, in-depth interviews with purposively selected participants at tertiary-level hospitals and a tuberculosis program coordinator at the Ethiopian Ministry of Health, who coordinates chest X-ray-guided systematic tuberculosis screening. A framework analysis was conducted using the consolidated framework for implementation research.

Results

We identified 11 constructs that influenced the implementation of the chest X-ray intervention. Facilitators included the relative sensitivity of chest X-ray over symptom-based screening, its potential integration into existing systems, technological advancements in the area, policies and laws supporting the screening intervention, and the quality of the evidence of the screening intervention. Barriers included implementation complexity, high costs of the intervention, knowledge gaps among healthcare providers, training gaps, low priority for chest X-ray screening at the healthcare facility level, and a lack of external support from the Ministry of Health and stakeholders.

Conclusion

This study identified contextual factors that influence the implementation of chest X-ray guided systematic tuberculosis screening among clinically high-risk groups that healthcare facilities and health ministries may use for decision-making. Addressing the barriers identified by the study would help to improve the implementation of chest X-rays for improved tuberculosis case detection and prompt treatment in clinically high-risk groups.

Clinical Characteristics and Survival of Patients with Malignant Ovarian Tumors in Addis Ababa, Ethiopia

BACKGROUND

Ovarian cancer is the third leading cause of cancer death among women in Ethiopia, with about 2,550 diagnosed cases and 2,000 deaths each year. The incidence and mortality rates of this disease have been increasing in Ethiopia and other parts of sub-Saharan Africa over the past decades because of changing lifestyle and reproductive factors. In this study, we describe the clinical characteristics, treatment patterns, and survival of patients with ovarian cancer in Ethiopia.

MATERIALS AND METHODS

This retrospective cohort study included 485 patients diagnosed between January 2009 and October 2015 at Addis Ababa University Hospital, Zewditu Memorial Hospital, or registered in the Addis Ababa population-based cancer registry. Follow-up data were obtained via telephone. Primary endpoint was all-cause mortality.

RESULTS

The median age was 46 years (range, 11-95). The estimated 1- and 2-year overall survival rates were 78% (95% confidence interval [CI] 0.741-0.82.5) and 59% (95% CI, 0.538-0.646), respectively. Of those patients with result available (n = 423), 73.0% had epithelial cancers. Almost half were classified as Federation of Gynecology and Oncology stage III or IV (48.2%; stage available n = 201) resulting in worse outcomes (hazard ratio [HR], 2.91 [CI 0.67-12.64] and 3.03 [0.69-15.79], respectively). Four out of five patients received some form of surgery (82%), three out of five received platinum-containing chemotherapy. Patients with residual tumor after surgery (n = 83) showed worse survival outcome (HR, 2.23; 95% CI 1.08-4.49).

CONCLUSION

Our study revealed substantial treatment gaps with respect to surgery and adequate chemotherapy. Higher stage, residual tumor and lack of chemotherapy impaired the outcome. Access to higher standards of ovarian cancer treatment is urgently needed in Ethiopia.

IMPLICATIONS FOR PRACTICE

Ovarian cancer is often a fatal disease in high resource settings; now it is also becoming important in Ethiopia. This study included 485 women with malignant ovarian tumors treated in Addis Ababa who had a mean age of only 46 years because of the young population structure. Three quarters had the typical epithelial cancer, with half presenting with advanced stage III and IV. Improved oncologic surgery and sufficient chemotherapy could possibly improve their outcome. The relatively high proportion of women with nonepithelial cancer need adequate treatment options to have good prognosis.

Automated Fetal Head Detection and Circumference Estimation from Free-Hand Ultrasound Sweeps Using Deep Learning in Resource-Limited Countries

Ultrasound imaging remains out of reach for most pregnant women in developing countries because it requires a trained sonographer to acquire and interpret the images. We address this problem by presenting a system that can automatically estimate the fetal head circumference (HC) from data obtained with use of the obstetric sweep protocol (OSP). The OSP consists of multiple pre-defined sweeps with the ultrasound transducer over the abdomen of the pregnant woman. The OSP can be taught within a day to any health care worker without prior knowledge of ultrasound. An experienced sonographer acquired both the standard plane-to obtain the reference HC-and the OSP from 183 pregnant women in St. Luke's Hospital, Wolisso, Ethiopia. The OSP data, which will most likely not contain the standard plane, was used to automatically estimate HC using two fully convolutional neural networks. First, a VGG-Net-inspired network was trained to automatically detect the frames that contained the fetal head. Second, a U-net-inspired network was trained to automatically measure the HC for all frames in which the first network detected a fetal head. The HC was estimated from these frame measurements, and the curve of Hadlock was used to determine gestational age (GA). The results indicated that most automatically estimated GAs fell within the P2.5-P97.5 interval of the Hadlock curve compared with the GAs obtained from the reference HC, so it is possible to automatically estimate GA from OSP data. Our method therefore has potential application for providing maternal care in resource-constrained countries.

Incidence and predictors of reinfection with Trichomonas vaginalis in HIV-infected women

BACKGROUND AND OBJECTIVES

The presence of sexually transmitted infections (STIs) may facilitate transmission of HIV to uninfected partners.

GOAL

To describe the incidence of reinfection with Trichomonas vaginalis in HIV-infected women and to assess predictors of reinfection.

STUDY DESIGN

A retrospective cohort study using data abstracted from medical records of HIV-infected women with at least one diagnosis of trichomoniasis.

RESULTS

Approximately one third (36%) of the study population was reinfected with T vaginalis during the follow-up period, with an incidence of 16.4 reinfections per 100 person years. Significant predictors of reinfection included history of another STI (hazard ratio, 1.52; 95% CI, 1.08-2.14) and becoming pregnant during the follow-up period (hazard ratio, 0.59; 95% CI, 0.39-0.87).

CONCLUSIONS

There is a high rate of reinfection with T vaginalis in HIV-infected women. Further research that includes information on sexual partners should be conducted to better describe the reinfection patterns of trichomoniasis.