Improvements in Child Cancer Diagnostics and Treatment in Africa

In Africa, more than 50% of cases of childhood cancer go undiagnosed. Africa accounts for 146,000 of the projected 397,000 new cases globally per year (including both diagnosed and undiagnosed cases) (Ward et al, 2019a). Of the diagnosed cases, only 11.6% of children in Africa survive (Ward et al, 2019b). Based on the above modeling exercise, we estimate that only about one-third of those who are diagnosed actually receive treatment; no hard data are available. Increasing access to treatment will increase survival, although to reach survival rates comparable to high income countries, investments will also be needed to decrease treatment abandonment and improve quality of treatment (Ward et al, 2019b).We recommend investing to expand treatment of five key cancers that are both treatable and affordable. These five cancers together account
for 40% of the burden of childhood cancer in Africa. Studies of cost per child treated in subSaharan Africa for three of the conditions (Burkitt lymphoma, nephroblastoma and earlystage retinoblastoma) were $1248, $1976 and $2202 USD respectively in various low- and lower-middle income countries in Africa. More conservatively, costs of a comprehensive cancer centre in one African country which achieved a projected 5-year survival rate of 35% for a cohort of children with multiple cancer types, were around $10,000 per child in 2018 USD, or around 6.5 times per capita GNI (see text below for all study references).
Benefit:cost ratios were estimated as 9.1 to 19.3 for the three diseases for which studies were available, and a more conservative 5.2:1 for a comprehensive centre which treats not only the priority diseases, but also provides treatment for other less-treatable conditions and palliative care to children for whom cure is not possible. Ratios would be a little lower (4.6:1) but still very attractive if indirect costs to families were included in treatment costs, and higher if non-profit organizations took the lead in small investments to reduce treatment abandonment rates, as has been done successfully in a number of low- and middleincome country (LMIC) contexts.
Expanding care from the estimated one-third of those diagnosed to all those currently diagnosed would cost $407m using the comprehensive cancer centre model. This amount would double, if 90% coverage of were attained (i.e. if 80% of all undiagnosed children could be diagnosed and linked to treatment). The value of the benefits would however be an estimated 5.2 times the costs, or $2116m. There are other potential unquantifiable benefits, such as helping to show that cancer is indeed curable and helping reduce the stigma associated with cancer in Africa, potentially leading adults with cancer to seek care earlier and improve their survival. In addition, improving capabilities to treat childhood cancers has the potential to strengthen health systems more broadly, by developing radiologic and pathologic services, medicines procurement and supply management, surgical facilities, health human resource training and retention, and supportive care capacities.

Nonphysician Sedation Providers in Africa: What Counts and What Is Being Counted?

“Not everything that can be counted counts, and not everything that counts can be counted.” – WB Cameron, Informal Sociology: A Casual Introduction to Sociological Thinking, 1963.

Does your anesthesia providers’ level of training impact your outcomes? This question has been widely evaluated and debated in the perioperative literature. With increasing demand for surgical and procedural services facilitated by anesthesia care globally, an answer will continue to be sought. Van der Merwe et al1 in their article “Postoperative outcomes associated with procedural sedation conducted by physician and non-physician anesthesia providers: findings from the prospective, observational African Surgical Outcomes Study (ASOS)” published in this month’s Anesthesia & Analgesia, have added to this discussion, with a secondary analysis of data from the African Surgical Outcomes Study (ASOS). Although their study provides some interesting insights into the outcomes of procedural sedation across the continent, our opinion is that the question remains largely unanswered.

To date, most of the literature evaluating the association between anesthesia care provider type and outcomes has focused on anesthesia care in highly developed health care systems. Questions have focused on task-shifting, where the responsibility for tasks is shifted from a more highly trained health care provider to health workers with shorter training and fewer qualifications, and task-sharing, where both levels of providers perform the task and may even work closely together. Examples include family doctors in Canada providing unsupervised anesthesia care in community hospitals after adding an additional year of training in anesthesia to their family medicine residency program; certified registered nurse anesthetists (CRNAs), practicing independently in many US states; and French anesthesiologists supervising nurse anesthetists with a 1:2 ratio. Ultimately, the hope is that by shifting/sharing tasks, access to care will improve with less-resource input and with similar (or in the case of task-sharing) even safer outcomes.2

Countries with a gross national income per capita of <$12,696 US dollars (USDs) are often (problematically) lumped together as low- and middle-income countries (LMICs)3 regardless of the profound diversity in this categorization, which contains around 85% of the world’s population.4 There is a critical shortage in human resources for health (HRH) globally, particularly in anesthesia. However, HRH are one of the most complex parts of health systems, with huge international variation in terms of numbers of health care workers, their training, their point of entry into training, their scope of practice, interprofessionalism, resilience, burnout, and retention of health care workers within the system.5–7 Developing a deep understanding of how to most effectively and efficiently provide safe anesthesia care is an urgent priority in improving global surgical outcomes; however, nuances in context make generalizations problematic.

Ven der Merwe et al1 aimed to evaluate this question by comparing patient outcomes when procedural sedation was delivered by nonphysician versus physician anesthesia providers. The primary data source, the ASOS, is a landmark study, where investigators collected a large amount of data (11,422 patients) over a relatively short amount of time, with good coverage of a broad geographic area.8 Its largely descriptive statistical analysis has been highly informative of perioperative outcomes in Africa, which appear to be much worse than previously published global data. In contrast, the Van der Merwe et al1 study is a small subset of the primary data (336 patients, ~3% of the full cohort), with a more complex comparative statistical analysis, with the authors concluding that receipt of sedation from a nonphysician provider was significantly associated with increased odds of severe complications. While these results must be interpreted with great caution (as we will outline below), the findings raise important questions about perioperative health care systems in Africa.

How Climate Change May Threaten Progress in Neonatal Health in the African Region

Climate change is likely to have wide-ranging impacts on maternal and neonatal health in Africa. Populations in low-resource settings already experience adverse impacts from weather extremes, a high burden of disease from environmental exposures, and limited access to high-quality clinical care. Climate change is already increasing local temperatures. Neonates are at high risk of heat stress and dehydration due to their unique metabolism, physiology, growth, and developmental characteristics. Infants in low-income settings may have little protection against extreme heat due to housing design and limited access to affordable space cooling. Climate change may increase risks to neonatal health from weather disasters, decreasing food security, and facilitating infectious disease transmission. Effective interventions to reduce risks from the heat include health education on heat risks for mothers, caregivers, and clinicians; nature-based solutions to reduce urban heat islands; space cooling in health facilities; and equitable improvements in housing quality and food systems. Reductions in greenhouse gas emissions are essential to reduce the long-term impacts of climate change that will further undermine global health strategies to reduce neonatal mortality.

Exposure to family planning messages and contraceptive use among women of reproductive age in Sub-Saharan Africa: A crosssectional program impact evaluation study

Many women of reproductive age in sub Saharan Africa are not utilizing any contraceptive method which is contributing to the high burden of maternal mortality. This study determined the prevalence, trends, and the impact of exposure to family planning messages (FPM) on contraceptive use (CU) among women of reproductive age in sub-Saharan Africa (SSA). We utilized the most recent data from demographic and health surveys across 26 SSA countries between 2013 and 2019. We assessed the prevalence and trends and quantified the impact of exposure to FPM on contraceptive use using augmented inverse probability weighting with regression adjustment. Sensitivity analysis of the impact estimate was conducted using endogenous treatment effect models, inverse probability weighting, and propensity score with nearest-neighbor matching techniques. The study involved 328,386 women of reproductive age. The overall prevalence of CU and the percentage of women of reproductive age in SSA exposed to FPM were 31.1% [95% CI: 30.6–31.5] and 38.9% [95% CI: 38.8–39.4] respectively. Exposure to FPM increased CU by 7.1 percentage points (pp) [95% CI = 6.7, 7.4] among women of reproductive age in SSA. The impact of FPM on CU was highest in Central Africa [6.7 pp; 95% CI: [5.7–7.7] and lowest in Southern Africa [2.2 pp; 95% CI: [1.3-3.0]. There was a marginal decline in the impact estimate among adolescents (estimate = 6.0 pp [95% CI = 5.0, 8.0]). Exposure to FPM has contributed to an increase in CU among women of reproductive age. Programs that are geared towards intensifying exposure to FPM through traditional media in addition to exploring avenues for appropriate use of electronic media remain critical.

Predictors and management outcomes of perforated appendicitis in sub-Saharan African countries: A retrospective cohort study

Background
Previous studies have found an association between various predictors and perforated appendicitis. However, there is limited evidence of studies determining the severity of acute appendicitis (AA) in resource-limited settings. Thus, this study aimed to identify predictors and outcomes of perforated appendicitis (PA) in sub-Saharan countries.

Methods
This is a retrospective cohort study of 298 adult patients who underwent surgical intervention for acute appendicitis. Demographic characteristics, clinical parameters, intraoperative findings, length of hospital stay, and postoperative complications were collected. We computed multivariate logistic regression to identify predictors of PA. P-value 38 °C (AOR = 4.569; 95% CI (2.249–9.282), and duration of symptoms >2 days (AOR = 2.704; 95% CI (1.400–5.222). Perforation was associated with an increased rate of postoperative complications (45.07vs. 6.41%; P 38 °C were the best predictors of PA. The overall total postoperative complications and the length of hospital stays were higher in PA. Based on our findings, we recommend that the identified predictors should be considered during the preoperative diagnosis and subsequent management.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

Purpose of Review
Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model.

Recent Findings
A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda.

Summary
Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.

Postoperative outcomes associated with surgical care for women in Africa: an international risk-adjusted analysis

Background
There is an increasing call for a broader approach to women’s surgical care in low- and middle-income countries, beyond access to caesarean section. While obstetric outcomes in Africa are well described, outcomes following non-obstetric surgical care for women in Africa are relatively unknown. Methods We did a secondary analysis of the African Surgical Outcomes Study (ASOS) focusing on severe postoperative complications (defined as death and severe complications) in females following non-obstetric, non-gynaecological surgical procedures. ASOS was a seven-day, African multi-centre prospective observational cohort study of adult (≥18 years) patients undergoing surgery in 25 African countries. These African outcomes were compared to international outcomes from the International Surgical Outcomes Study (ISOS) in a riskadjusted logistic regression analysis. Findings There were 1498 African participants and 18449 international participants who met the inclusion criteria. The African cohort were younger than the international cohort (47 (17) years versus 57 (17); p= <0·0001) and had a lower preoperative risk profile. Severe complications occurred in 41 (2·8%) of 1471 patients of the African cohort, and 431 (2·3%) of 18449 patients in the ISOS cohort, with in-hospital mortality following severe complications of 20/41 (48·8%) in ASOS and 78/431 (18·1%) in ISOS. The adjusted odds ratio for a woman in Africa developing a severe postoperative complication following elective non-obstetric, non-gynaecological surgery compared to the international incidence was 2·114 (95% CI 1·468 – 3·042, p<0·0001). Interpretation: Women living in Africa have double the odds of severe postoperative complications following elective non-obstetric, non-gynaecological surgery compared to the international incidence.

Exploring the feasibility of integration of surveillance for intussusception into the routine monitoring of adverse events following immunization by countries of the WHO African Region for Africa

Surveillance for intussusception (IS) post-rotavirus vaccine introduction in World Health Organization Africa Region (WHO/AFRO) has been restricted mainly to the large referral teaching hospitals. The choice of these facilities for surveillance was made to utilize the abundant expertise of specialists in paediatrics and surgery in these hospitals who can diagnose and manage such patients with IS. The surveillance has been well coordinated by the African Intussusception Surveillance Network established in 2012. This network has supported surveillance across the African region and has accumulated a huge database of IS cases in children < 1 year with findings that have demonstrated safety of the monovalent rotavirus vaccine, Rotarix (GlaxoSmithKline). However, safety data on the pentavalent and RotaTeq (Merck Vaccine) is not yet available from the African region. Although, this network has provided much needed data, there is an inherent bias in monitoring and reporting of IS cases in only large tertiary hospitals. This time limited special project does not capture suspected intussusception cases with no access to hospital facilities used for monitoring IS. Additionally, the design requires extensive resources to support collection of high-quality data for monitoring IS, which is unsustainable. For these reasons suitable linkages between IS monitoring and routine Adverse Event Following Immunization (AEFI) should be established for continuity of monitoring of this condition. We propose alignment of the two systems that offers opportunity for high profile recognition and to enhance a sustainable system for diagnosis, treatment and continuous assessment of intussusception occurring in infancy.

Quality of health care services and performance in public hospitals in Africa: A protocol for systematic review

Background: The delivery of high-quality health care services and performance is the main aim of all health care systems globally. This review objective is to determine the quality of health care services and performance in public hospitals in Africa through a systematic review and meta-analysis of existing studies.

Methods: The search will be conducted in pre-determined databases (e.g., PubMed), for eligible studies between 2000 and 2020, to identify studies published in English, which applied the service quality gap (SERVIQUAL) model to determine the quality of health care services and performance in public hospitals in Africa. The search will also include a review of reference lists of included studies for other eligible studies. Eligible studies will include experimental and observational studies. Two authors will independently screen the search output, select studies and extract data, resolve discrepancies by consensus and discussions. Two authors will use Cochrane risk of bias tools for experimental studies, and Hoy for observational studies. The review will also assess study quality and risk of bias using standardized tools. The review aims to provide comprehensive information on the quality of health care services and performance in public hospitals in Africa.

Discussion: Understanding patients’ or clients’ expectations and perceptions on the quality of health care services provided in the health care systems are very crucial in the improvement of the health status of the general population. The SERVIQUAL model is a standardized tool used to assess the quality gap of patients/clients perspectives on health care services in hospitals globally. The findings from this review will provide information on the quality gap of health care provided in public hospitals in SSA. Also, we anticipate that the findings will inform policymakers in health care systems on how to improve and maintain the quality of health care services in public hospitals in different African settings.

Systematic review registration number: PROSPERO CRD 420212264100 dated 25/07/2021

Burden and trend of colorectal cancer in 54 countries of Africa 2010–2019: a systematic examination for Global Burden of Disease

Background
Colorectal cancer plays significant role in morbidity, mortality and economic cost in Africa.

Objective
To investigate the burden and trends of incidence, mortality, and disability-adjusted life-years (DALYs) of colorectal cancer in Africa from 2010 to 2019.

Methods
This study was conducted according to Global Burden of Disease (GBD) 2019 analytic and modeling strategies. The recent GBD 2019 study provided the most updated and compressive epidemiological evidence of cancer incidence, mortality, years lived with disability (YLDs), years of life lost (YLLs), and DALYs.

Results
In 2019, there were 58,000 (95% UI: 52,000–65,000), 49,000 (95% UI: 43,000–54,000), and 1.3 million (95% UI: 1.14–1.46) incident cases, deaths and DALYs counts of colorectal cancer respectively in Africa. Between 2010 and 2019, incidence cases, death, and DALY counts of CRC were significantly increased by 48% (95% UI: 34–62%), 41% (95% UI: 28–55%), and 41% (95% UI: 27–56%) respectively. Change of age-standardised rates of incidence, death and DALYs were increased by 11% (95% UI: 1–21%), 6% (95% UI: − 3 to 16%), and 6% (95% UI: − 5 to 16%) respectively from 2010 to 2019. There were marked variations of burden of colorectal cancer at national level from 2010 to 2019 in Africa.

Conclusion
Increased age-standardised death rate and DALYs of colorectal cancer indicates low progress in CRC standard care-diagnosis and treatment, primary prevention of modifiable risk factors and implementation of secondary prevention modality. This serious effect would be due to poor cancer infrastructure and policy, low workforce capacity, cancer center for diagnosis and treatment, low finical security and low of universal health coverage in Africa.