Are we ready for a sustainable approach? A qualitative study of the readiness of the public health system to provide STI services to the key populations at risk of HIV in Bangladesh

INTRODUCTION

In Bangladesh, sexually transmitted infection (STI) services are available for all populations in public health facilities. However, STI services for key populations (KPs) at risk of HIV need specifically designed approaches that are predominantly administered to KPs through donor-supported service centers operated by non-government organizations (NGOs) and community-based organisations (CBOs). However, the steady decline in donor funding warrants a sustainable transition of STI services for the KPs into public health facilities. This article aimed to explore the service availability and readiness of public health facilities to provide STI services for the KPs.

METHODS

This qualitative study explored the service availability and readiness of public health facilities in three districts of Bangladesh by adapting the Service Availability and Readiness Assessment tool. We conducted 34 in-depth interviews,11 focus group discussions with KPs, and 29 key-informant interviews with healthcare providers, researchers, programme implementers and policy planners, in addition to series of direct observations at the public healthcare facilities. Data were analysed through thematic analysis, and categorised in relation to the WHO building blocks.

RESULTS

This study revealed that the public health system was generally not ready to serve the KPs' needs in terms of providing them with quality STI services. The 'service delivery' component, which is the most crucial facet of the public health system, was not ready to provide STI services to KPs. Findings also indicated that health workforce availability was limited in the primary and secondary healthcare layers but adequate in the tertiary layer, but needed to be oriented on providing culturally sensitised treatment. Counseling, an essential component of STI services, was neither ready nor available. However, health information systems and a few other components were partially ready, although this warrants systematic approaches to address these challenges.

CONCLUSION

The findings show that public health facilities are yet to be fully ready to render STI services to KPs, especially in terms of service delivery and human and health resources. Therefore, it is not only integral to mobilize communities towards the uptake of public health services, but health systems need to be prepared to cater to their needs.

An improved, simple and field deployable CRISPR-Cas12a assay for detection of SARS-CoV-2

AIMS

The RT-PCR is the most popular confirmatory test for SARS-CoV-2. It is sensitive, but high instrumentation cost makes it difficult for use outside routine clinical setup. This has necessitated development of alternative methods such as CRISPR-based DETECTR method which uses lateral flow technology. Though accurate and sensitive, this method is limited by complex steps and recurrent cost of high quality lateral flow strips. The main goal of this study was to improve the Cas12a-based SARS-CoV-2 DETECTR method and develop a portable and field deployable system to reduce the recurring consumable cost.

METHODS AND RESULTS

Specific regions of N and E genes from SARS-CoV-2 virus and human RNase P (internal control) were reverse transcribed (RT) and amplified by loop-mediated isothermal amplification (LAMP). The amplified products were detected by a Cas12a-based trans-cleavage reaction that generated a fluorescent signal which could be easily visualised by naked eye. Detection of internal control, RNase P gene was improved and optimised by re-designing RT-LAMP primers. Number of steps were reduced by combining the reagents related to detection of Cas12a trans-cleavage reaction into a single ready-to-use mix. A portable, cost-effective battery-operated instrument, CRISPR-CUBE was developed to run the assay and visualise the outcome. The method and instrument were validated using both contrived and patient samples.

CONCLUSIONS

The simplified CRISPR-based SARS-CoV-2 detection and instrument developed in this study, along with improved design for internal control detection allows for easier, more definitive viral detection requiring only reagents, consumables and the battery operable CRISPR-CUBE.

SIGNIFICANCE AND IMPACT OF STUDY

Significant improvement in Cas12 method, coupled with simple visualisation of end-point makes the method and instrument deployable at the point of care for SARS-CoV-2 detection, without any recurrent cost for the lateral flow strips which is used in other POC methods.

National TB Control Program of Bangladesh: System Failure and Loss of Effectiveness

The National Tuberculosis Control Program (NTP) is one of the largest programs run by the state with many successes. However, underreporting is considered a real flaw of the current program. To report the characteristics and outcomes of TB patients registered in an upazila health complex in Kazipur, Sirajganj district, Bangladesh between September 2018 and February 2019 under the control of NTP was the objective of the study. This retrospective cohort study was conducted using routinely collected program data from the aforementioned site. Data retrieved from the hospital record form. Formal permission was obtained from the local authority. Consent statements and ethical aspects were waived due to the retrospective nature of the study. Analysis was performed using SPSS 20.0. A total of 207 tuberculosis cases were included with an average age of presentation of 43 years. Approximately 82.0% had pulmonary tuberculosis (PTB) and the rest had extrapulmonary tuberculosis (EPTB). PTB was more common in males, whereas EPTB was common in females (p=0.01). Of all cases, 84.0% were diagnosed by a positive sputum smear and 16.0% were diagnosed clinically with a negative sputum smear. Attendance at follow-up was 82.12%, 70.04% and 68.59% at months 2, 5 and 6 following index admission respectively. Overall, the cure rate was higher in PTB than EPTB [146 (85.9%) vs. 5 (13.5%), p<0.001). The rate of treatment completion was 25.1% (n=52) and the death count was 1.4% (n=3) [PTB-1.2 (n=2) vs. EPTB-2.7% (n=1)]. A gradual decline in reporting or completion of treatment was observed in this setting. However, a nationwide study is warranted to explore this issue in detail.

The willingness to receive sexually transmitted infection services from public healthcare facilities among key populations at risk for human immunodeficiency virus infection in Bangladesh: A qualitative study

Background

In Bangladesh, community-based and peer-led prevention interventions for human immunodeficiency virus infection are provided to key populations (KPs) by drop-in centers (DICs), which are primarily supported by external donors. This intervention approach was adopted because public healthcare facilities were reportedly insensitive to the needs and culture of KPs, particularly with regard to the provision of sexually transmitted infection (STI) services. Nonetheless, in the absence of external funding, STI services need to be integrated into public healthcare systems.

Methods

A qualitative study was conducted in 2017 to understand the willingness of KPs to uptake the STI services of public healthcare facilities. Data were collected based on 34 in-depth interviews, 11 focus group discussions, and 9 key informant interviews. The social-ecological theoretical framework was used to analyze the data thematically and contextually.

Results

Most participants were either resistant or reluctant to uptake STI services from public healthcare facilities because of their previous firsthand experiences (e.g., disrespectful and judgmental attitudes and behaviors), perceived discrimination, anticipatory fear, and a lack of privacy. Very few participants who had visited these facilities to receive STI services were motivated to revisit them. Nevertheless, they emphasized their comfort in DICs over public healthcare facilities. Thus, it appears that KPs can be situated along a care-seeking continuum (i.e., resistance to complete willingness). Unless policymakers understand the context and reasons that underlie their movement along this continuum, it would be difficult to encourage KPs to access STI services from public healthcare facilities.

Conclusion

KPs’ willingness to uptake the STI services of public healthcare facilities depends not only on individual and community experiences but also on the nexus between socio-structural factors and health inequalities. Community mobilization and training about the needs and culture of KPs for healthcare professionals are essential. Therefore, addressal of a wide range of structural factors is required to motivate KPs into seeking STI services from public healthcare facilities.

Assessment of DNA Methylation in p15, p16 and E-Cadherin Genes as a Screening Tool for Early Carcinoma Cervix

Cancer cervix is diagnosed late in women due to anatomical inaccessibility of the area. Hence, a robust screening strategy will help detect carcinoma cervix early which will significantly decrease the mortality and morbidity due to this disease. We evaluated DNA methylation of three tumour suppressor genes p15, p16 and E-Cadherin on cervical smears to assess DNA methylation as a screening tool for detection of early cervical cancer in comparison to PAP smears. DNA was extracted from cervical smears of 20 cases and 30 controls. The DNA was bisulphite modified. Methylation specific PCR (MSP) was performed to assess the methylation status of the promoter region of each of the genes. MSP results were compared with PAP smears to assess the utility of DNA methylation of these genes in screening for cervical cancer. DNA methylation was detected in 55% subjects in p15 gene, 45% in p16 gene and 40% in E-Cadherin gene. This was statistically significant when compared to the controls. DNA methylation of E-Cadherin, and p15 genes as a panel has a sensitivity and specificity of 80% and 90% respectively, which is better than the sensitivity of PAP smear for detection of early cancer cervix. Increased DNA methylation is seen in p15, p16 and E-Cadherin genes in early cancer cervix. p15 and E-Cadherin in combination can be used as a screening tool for detection of early cancer cervix.

MODIFIED BROMOPHENOL BLUE DYE BINDING METHOD FOR QUANTITATION OF MICROALBUMINURIA IN DIABETES MELLITUS

Albumin excretion in microalbuminuria range is one of the earliest manifestation of nephropathy, specially in diabetes mellitus. The modified dye binding method using bromo-phenol blue was studied in 27 healthy controls and 54 patients of diabetes mellitus, negative for albuminuria by albustix test. The analytical recovery (99.4 to 104.0%), within run coefficient of variation (0.8 to 0.36%) and day-to-day coefficient of variation (2.39 to 0.82%), for low and higher range were within acceptable limits. The values in controls ranged as follows: urinary albumin concentration (mg/L) 7.7 - 28.4 in 2-hour specimen and 10.3 - 29.2 in overnight specimen; albumin excretion rate (µg/min) 7.8 - 29.7 in 2-hour and 9.2 - 29.6 in overnight specimen; and albumin creatinine ratio (mg/g) 10.6 - 29.6 in 2-hour and 11.9 - 29.6 in overnight specimens. Correlation analysis of various albumin excretion parameters revealed excellent correlation between estimations from overnight and 2-hour samples for albumin-creatinine ratio (r = 1.00) and albumin excretion rate (r=0.96). Equally good correlation was observed between 2-hour albumin-creatinine ratio and albumin excretion rate (r=0.95). In 10 of 54 patients excretion rate was more than 200 µg/min and could have been detected by repeat albustix test. Of the 36 positive for microalbuminuria, 21 had one or more target organ involvement. There was no target organ involvement in 8 patients negative for microalbuminuria. Screening for microalbuminuria by this simple and economic method, using 2-hour albumin-excretion rate or albumin-creatinine ratio could be one of the earliest investigations in diabetic patients.

Correlation of Microalbuminuria with Estimated GFR (eGFR) by Cockcroft-Gault and MDRD Formula in Type 2 Diabetics and Hypertensives

Increase in urine albumin excretion rate (AER) precede a fall in glomerular filtration rate in patients developing diabetic chronic kidney disease (CKD). Our results have shown that 7 (50 %) of diabetic and hypertensive individuals with decreased GFR do not have increased AER. In this cross-sectional study, we measured AER of 75 patients with type 2 diabetes and hypertension by immunoturbidimetric method. We correlated the results with eGFR values obtained by Cockcroft-Gault and MDRD method. The method used was not a compensated method. We measured serum creatinine by modified Jaffe's kinetic method in autoanalyzer XL-600. Analysis of data showed positive correlation between eGFR and microalbuminuria by both the methods with eGFR <60 mL/min/1.73 m(2). Pearson's correlation co-efficient (r) was 0.9 (p = 0.0001) by Cockcroft-Gault formula and 0.69 (p = 0.0063) by MDRD formula. Our results concluded that there was positive correlation between AER and eGFR <60 mL/min/1.73 m(2). We have recognized that these two parameters provide a complimentary benefit in management of cases with CKD.

Comparative study of serum amylase and lipase in acute pancreatitis patients

To establish utility of single enzymatic marker for the diagnosis of acute pancreatitis. This is a cohort study. Tertiary care centre proven cases of acute pancreatitis (n = 50) admitted in surgery ward between December 2011 and May 2013 were included in the study. Serum amylase and lipase were performed along with many analytes. All relevant data including serum lab values and imaging were collected. All 50 patients included in the study had raised serum lipase, 42 patients had both amylase and lipase raised, 8 patients had amylase normal but lipase raised. In smaller hospitals where limited lab and radiological facilities are available, estimation of serum lipase will be a better choice over serum amylase in diagnosis of acute pancreatitis.

Demographic profile and outcome analysis of a paediatric intensive care unit in a paediatric hospital in Kolkata

A prospective observational study was performed to know the profile and outcome of paediatric Intensive care unit admitted patients. Paediatric intensive care unit admitted patients are mostly male (65%), suffering from critical respiratory (36%) and CNS diseases (35.4%). The survival at paediatric intensive care unit was 37.5% (25% were mechanically ventilated). Successful mechanical ventilation was done for 45 days. Major cause of mortality was sepsis with multiorgan dysfunction. Commonest organism Isolated from blood was Klebsiella pneumoniae (38%). Most Gram-negative organisms were sensitive only to carbapenems, some were sensitive only to polymyxin B. All staphylococci were resistant to vancomycin.

Maxillary osteonecrosis and spontaneous teeth exfoliation following herpes zoster

BACKGROUND

Reports of osteonecrosis and spontaneous tooth loss following herpes zoster infection of the fifth cranial are extremely rare. Only 39 previously recorded cases of post-zoster osteonecrosis have been found in the literature. The unusual feature of the case of interest to the dental surgeon is a rare complication of tooth exfoliation and maxillary osteonecrosis.

CASE REPORT

This article reports a case of 52-year-old man with herpes zoster infection of the trigeminal nerve and related alveolar bone necrosis and teeth loss. The etiology and management of herpes zoster infection associated with destructive sequelae are discussed.

DISCUSSION

Very few cases of osteonecrosis and spontaneous teeth exfoliation secondary to herpes zoster are found in the literature. The exact mechanism by which herpes zoster induces these destructive changes in the alveolar bone and teeth cannot be proposed. As Varicella zoster virus is an aneurotropic virus, the possible provoking factors may be the infection of the nerves innervating the periosteum or the chronic inflammatory changes in the form of adverse periodontal disease and delayed healing of the extraction sockets associated with compromised host resistance.

Conversion from mycophenolate mofetil to enteric-coated mycophenolate sodium in renal transplant recipients with gastrointestinal tract disorders

OBJECTIVE

The objective of this prospective study was to evaluate the effect of conversion from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS) in renal transplant recipients with gastrointestinal tract (GI) reverse effects using patient-reported outcomes instrument.

METHODS

A multicenter, open-label, prospective study was undertaken in renal transplant recipients treated with MMF. In patients experiencing GI tract symptoms, treatment was changed to equimolar EC-MPS (myfortic). At baseline and visit 2 (4-6 weeks after baseline), patients completed the Gastrointestinal Symptom Rating Scale (GSRS) and Gastrointestinal Quality of Life Index (GIQLI), and physicians completed the Overall Treatment Effect (OTE) scale at visit 2. A difference of 0.5 or greater in the OTE score is indicative of clinical relevance.

RESULTS

Of 154 patients screened, 118 fulfilled the inclusion or exclusion criteria. Eighty-five men and 33 women with a mean age of 41.6 years participated in this study. Median time since transplantation was 12 months. Mean (SD) dose of MMF reported at baseline was 1209.4 (422.89) mg/d. More than 50% of patients reported MMF-associated nausea, dyspepsia, and abdominal pain. After conversion to an equimolar dose of EC-MPS, patients showed improvement in GI symptoms. This benefit was predominantly observed in patients with moderate to severe symptoms at baseline. On the GSRS, patients reported a significant (P < .05) reduction in symptom burden across all parameters (reflux, 36%; diarrhea, 38%; indigestion, 36%; constipation, 28%; and abdominal pain, 40%). On the GIQLI also, significant (P < .05) improvement was reported (symptoms, 18%; emotional status, 22%; physical functioning, 21%, and use of medical treatment, 18%). On the OTE scale, 84.7% of patients reported improvement in GI symptoms.

CONCLUSION

In patients with moderate to severe GI symptoms, changing treatment from MMF to EC-MPS significantly reduces GI-related symptom burden and improves GI-specific quality of life.

Risk Factors for Coronary Artery Disease in Indians

BACKGROUND

A case control study was carried out to study the emerging risk factors for coronary artery disease in Indians.

METHODS

The diagnosis of coronary artery disease was based on correlation of clinical, biochemical, electrocardiography, echocardiography, treadmill testing and coronary arteriography findings. The study comprised 100 cases of coronary artery disease (acute coronary syndrome and chronic coronary artery disease) and 100 controls in two tertiary care service hospitals. The subjects were evaluated for total plasma homocysteine, insulin, C-reactive protein (CRP), lipoprotein fibrinogen and anti-chlamydial anti-bodies.

RESULT

Male to female ratio was 10:1 in study group with similar predominance of males in controls. Mean age of the cases was 47 years (range 25-59 years) and that of controls was 43 years (range 23-56 years). 64% cases had acute coronary syndrome and 34% had chronic coronary artery disease. In the coronary artery disease population, 76% cases had hyperhomocyteinemia, 9% hyperinsulinaemia, 11% abnormal CRP values, 23% abnormal lipoprotein (a) levels, 40% IgG anti-chlamydial anti-bodies and only 11% had Ig M anti-chlamydial antibodies. In the control population, 72% had hyperhomocystinaemia and 6% hyperinsulinaemia while 23% and 9% controls had IgG and IgM anti chlamydial antibodies respectively. In control group 19% cases had abnormal lipoprotein(a) levels and only 2% had abnormal C reactive protein values. Significant correlation of CAD was seen with CRP values and Ig G anti-chlamydial antibodies. Both the study group and controls had higher homocysteine levels than that observed in some Indian and Western studies.

CONCLUSION

High C reactive protein levels and Ig G anti-chlamydial antibodies are associated with coronary artery disease in Indians. Insulin, lipoprotein A, fibrinogen, lgM anti-chlamydial antibodies and higher levels of total plasma homocysteine have no significant association with coronary artery disease.

Endoscopic injection sclerotherapy control of intractable hematuria following radiation-induced hemorrhagic cystitis. A novel approach

OBJECTIVE

To establish the utility of endoscopic sclerotherapy using 1% ethoxysclerol for the control of intractable hematuria following post-irradiation telangiectatic cystitis (PTC).

METHODS

Our experience of treating 4 patients (one female and three male) with massive exsanguinating hematuria resulting from PTC, using a combined intralesional and perilesional injection of 1% ethoxysclerol, is presented. Observation on the distribution, grading of telangiectasis and pattern of bleeding are made.

RESULTS

A dramatic and lasting cessation of the hematuria in all the 4 patients was achieved during the follow-up period varying from 1 month to 4 years.

CONCLUSION

Endoscopic injection sclerotherapy is a simple, highly effective, less invasive new technique in the management of massive and intractable hematuria due to radiation-induced telangiectasia of the urinary bladder.

Invasion of small intestinal mucosa by Giardia lamblia in man

The mucosal biopsies from duodenum and jejunum of 31 patients showing Giardia lamblia in their feces were studied histologically. Although the trophozoites were found in all the biopsy specimens in the luman, the tissue invasion by the parasites in different stages, from their entry through the epithelium to the lamina propria could be demonstrated in 12 of them, all of the latter having diarrhea and steaterrhea. Varying histological changes in jejunal mucosa were also observed in 9 cases, of which 7 showed mucosal invasion by giardia trophozoites. In 17 of the series neither tissue invasion by the parasite nor mucosal change could be found.