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The cumulative clinical observations of physicians who cared for more than 700 patients with Ebola virus disease in Liberia between August and October of this year support a rational approach to EVD management in resource-limited settings. In resource-limited areas, isolation of the sick from the population at large has been the cornerstone of control of Ebola virus disease (EVD) since the virus was discovered in 1976. 1 Although this strategy by itself may be effective in controlling small outbreaks in remote settings, it has offered little hope to infected people and their families in the absence of medical care. In the current West African outbreak, infection control and clinical management efforts are necessarily being implemented on a larger scale than in any previous outbreak, and it is therefore appropriate to reassess traditional efforts at disease management. Having . . .

The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments. We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people's experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions. MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group. Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.

Outbreaks of methanol poisoning occur frequently on a global basis, affecting poor and vulnerable populations. Knowledge regarding methanol is limited, likely many cases and even outbreaks go unnoticed, with patients dying unnecessarily. We describe findings from the first three large outbreaks of methanol poisoning where Médecins Sans Frontières (MSF) responded, and evaluate the benefits of a possible future collaboration between local health authorities, a Non-Governmental Organisation and international expertise. Retrospective study of three major methanol outbreaks in Libya (2013) and Kenya (May and July 2014). Data were collected from MSF field personnel, local health personnel, hospital files, and media reports. In Tripoli, Libya, over 1,000 patients were poisoned with a reported case fatality rate of 10% (101/1,066). In Kenya, two outbreaks resulted in approximately 341 and 126 patients, with case fatality rates of 29% (100/341) and 21% (26/126), respectively. MSF launched an emergency team with international experts, medications and equipment, however, the outbreaks were resolving by the time of arrival. Recognition of an outbreak of methanol poisoning and diagnosis seem to be the most challenging tasks, with significant delay from time of first presentations to public health warnings being issued. In spite of the rapid response from an emergency team, the outbreaks were nearly concluded by the time of arrival. A major impact on the outcome was not seen, but large educational trainings were conducted to increase awareness and knowledge about methanol poisoning. Based on this training, MSF was able to send a local emergency team during the second outbreak, supporting that such an approach could improve outcomes. Basic training, simplified treatment protocols, point-of-care diagnostic tools, and early support when needed, are likely the most important components to impact the consequences of methanol poisoning outbreaks in these challenging contexts.

Low adherence to medications, specifically in patients with Diabetes (DM) and Hypertension (HTN), and more so in refugee settings, remains a major challenge to achieving optimum clinical control in these patients. We aimed at determining the self-reported medication adherence prevalence and its predictors and exploring reasons for low adherence among these patients. A mixed-methods study was conducted at Médecins Sans Frontières non-communicable diseases primary care center in the Shatila refugee camp in Beirut, Lebanon in October 2018. Data were collected using the validated Arabic version of the 8-items Morisky Medication Adherence Scale (MMAS-8) concurrently followed by in-depth interviews to explore barriers to adherence in patients with DM and/or HTN. Predictors of adherence were separately assessed using logistic regression with SPSS© version 20. Manual thematic content analysis was used to analyze the qualitative data. Of the 361 patients included completing the MMAS, 70% (n = 251) were moderately to highly adherent (MMAS-8 score = 6 to 8), while 30% (n = 110) were low-adherent (MMAS-8 score<6). Patients with DM-1 were the most likely to be moderately to highly adherent (85%; n = 29). Logistic regression analysis showed that patients with a lower HbA1C were 75% more likely to be moderately to highly adherent [(OR = 0.75 (95%CI 0.63-0.89), p-value 0.001]. Factors influencing self-reported moderate and high adherence were related to the burden of the disease and its treatment, specifically insulin, the self-perception of the disease outcomes and the level of patient's knowledge about the disease and other factors like supportive family and healthcare team. Adherence to DM and HTN was good, likely due to a patient-centered approach along with educational interventions. Future studies identifying additional factors and means addressing the barriers to adherence specific to the refugee population are needed to allow reaching optimal levels of adherence and design well-informed intervention programs.

In sub-Saharan Africa there is an increasing need to leverage available health care workers to provide care for non-communicable diseases (NCDs). This study was conducted to evaluate adherence to Médecins Sans Frontières clinical protocols when the care of five stable NCDs (hypertension, diabetes mellitus type 2, epilepsy, asthma, and sickle cell) was shifted from clinical officers to nurses. Descriptive, retrospective review of routinely collected clinic data from two integrated primary health care facilities within an urban informal settlement, Kibera, Nairobi, Kenya (May to August 2014). There were 3,554 consultations (2025 patients); 733 (21%) were by nurses out of which 725 met the inclusion criteria among 616 patients. Hypertension (64%, 397/616) was the most frequent NCD followed by asthma (17%, 106/616) and diabetes mellitus (15%, 95/616). Adherence to screening questions ranged from 65% to 86%, with an average of 69%. Weight and blood pressure measurements were completed in 89% and 96% of those required. Laboratory results were reviewed in 91% of indicated visits. Laboratory testing per NCD protocols was higher in those with hypertension (88%) than diabetes mellitus (67%) upon review. Only 17 (2%) consultations were referred back to clinical officers. Nurses are able to adhere to protocols for managing stable NCD patients based on clear and standardized protocols and guidelines, thus paving the way towards task shifting of NCD care to nurses to help relieve the significant healthcare gap in developing countries.

The 2014-15 Ebola outbreak in West Africa was disruptive for the general health services in the affected countries. This study assessed the impact of the outbreak on the reported number and management of malaria in children under-five in rural Guinea. A retrospective cross-sectional study was conducted in nineteen health centres in two rural, malaria-endemic health districts, one at the epicentre of the outbreak (Guéckédou) and one (Koubia) spared by Ebola. Routine surveillance data at health facility level were compared over similar periods of high malaria transmission in both districts before, during and after the outbreak. There were significant declines in the number of visits during the Ebola outbreak (3,700) in Guéckédou compared to before (4,616) and after it (4,195), while this trend remained more stable within the three periods for Koubia. Differences were nonetheless significant in both districts (p<0.001). In 2014, during the peak of the outbreak, the overall number of malaria cases treated exceeded the number of confirmed malaria cases in Guéckédou. There were decreases in antimalarial treatment provision in August and November 2014. In contrast, during 2015 and 2016, the proportion of malaria positive cases and those treated were closely aligned. During the peak of the Ebola outbreak, there was a significant decrease in oral antimalarial drug administration, which corresponded to an increase in injectable antimalarial treatments. Stock-outs in rapid diagnostic tests were evident and prolonged in Guéckédou during the outbreak, while more limited in Koubia. The Ebola outbreak of 2014-15 in Guinea had a significant impact on the admission and management of malaria in children under-five. This study identifies potential challenges in the delivery of care for those at highest risk for malaria mortality during an Ebola outbreak and the need to improve preparedness strategies pre-Ebola and health systems recovery post-Ebola.

Background Sudan is a fragile developing country, with a low expenditure on health. It has been subjected to ongoing conflicts ever since 1956, with the Darfur crisis peaking in 2004. The conflict, in combination with the weak infrastructure, can lead to poor access to healthcare. Hence, this can cause an increased risk of infection, greater morbidity and mortality from tuberculosis (TB), especially amongst the poor, displaced and refugee populations. This study will be the first to describe TB case notifications, characteristics and outcomes over a ten-year period in Darfur in comparison with the non-conflict Eastern zones within Sudan. Methods A cross-sectional review of the National Tuberculosis Programme (NTP) data from 2004 to 2014 comparing the Darfur conflict zone with the non-conflict eastern zone. Results New case notifications were 52% lower in the conflict zone (21,131) compared to the non-conflict zone (43,826). Smear-positive pulmonary TB (PTB) in the conflict zone constituted 63% of all notified cases, compared to the non-conflict zone of 32% ( p  < 0.001). Extrapulmonary TB (EPTB) predominated the TB notified cases in the non-conflict zone, comprising 35% of the new cases versus 9% in the conflict zone ( p  < 0.001). The loss to follow up (LTFU) was high in both zones (7% conflict vs 10% non-conflict, p  < 0.001) with a higher rate among re-treatment cases (12%) in the conflict zone. Average treatment success rates of smear-positive pulmonary TB (PTB), over ten years, were low (65-66%) in both zones. TB mortality among re-treatment cases was higher in the conflict zone (8%) compared to the non-conflict zone (6%) ( p  < 0.001). Conclusion A low TB case notification was found in the conflict zone from 2004 to 2014. High loss to follow up and falling treatment success rates were found in both conflict and non-conflict zones, which represents a significant public health risk. Further analysis of the TB response and surveillance system in both zones is needed to confirm the factors associated with the poor outcomes. Using context-sensitive measures and simplified pathways with an emphasis on displaced persons may increase access and case notification in conflict zones, which can help avoid a loss to follow up in both zones.

[This corrects the article DOI: 10.1371/journal.pone.0152676.].

Neonatal sepsis is a leading cause of morbidity and mortality in developing countries. This study aimed to assess the proportion of culture-confirmed sepsis, bacteriological pathogen profile, culture report turnaround times, antibiotic susceptibility patterns, and treatment outcomes of all with neonatal sepsis admitted in two tertiary care hospitals in Yangon, Myanmar, 2017–2019. This was a cross sectional study utilizing a standardized electronic database and paper-based records. Bacteriological profiles and associated factors were analyzed with descriptive statistics and Poisson Regression. Of those with suspected sepsis, 42% were bacteriologically confirmed and 74% of confirmed sepsis was resistant to at least first-line antibiotics. Neonates with late onset sepsis (LOS) (aPR: 1.2 (95% CI: 1.1–1.4, p = 0.008)) were more likely to have bacteriologically confirmed sepsis (45%) versus early onset sepsis (38%). Gram-negative organisms were most commonly isolated (63%), associated with multidrug-resistant organisms and with a high case-fatality rate (64%). These findings suggest that enhanced national guidance regarding infection control and prevention, antibiotic stewardship, and first-line antibiotic choices need to be provided. The link between LOS with infection and prevention protocols needs to be further explored in this context to decrease sepsis risk, neonatal mortality, and reduce further antimicrobial resistance.

Background In 2013, the World Health Organisation (WHO) recommended Option B+ as a strategy to prevent mother-to-child transmission (PMTCT) of HIV. In option B+ , lifelong antiretroviral therapy (ART) is offered to all HIV positive pregnant and breastfeeding women to reduce MTCT rate to less than or equal to 5%. Its success depends on retaining women on ART during pregnancy, delivery and breast-feeding period. There is limited data on early retention on ART among pregnant women in Zimbabwe. We therefore assessed early retention among women on Option B + from antenatal care (ANC) until 6 months post ANC booking and at delivery in Bulawayo city and Mazowe rural district of Zimbabwe. Methods We collected data for pregnant women booking for ANC between January and March 2018, comparing early retention among ART naïve women and those already on ART. The two cohorts were followed up for 6 months post ANC booking, and this was done in two districts. Data were collected from routine tools used at facility level which include ANC, delivery and ART registers. The Kaplan-Meier survival analysis was used to estimate retention probabilities at 1, 3 and 6 months post-delivery and for retention at delivery proportions were used. Poisson regression was used to investigate factors associated with non-retention at 6 months post ANC booking. Results A total of 388 women were included in the study with median age of 29 years (IQR: 25–34). Two-thirds booked in their second trimester. Retention at 3 and 6 months post ANC booking was 84% (95% CI 80–88) and 73% (95% CI 69–78) respectively. At delivery 81% (95% CI 76–84) were retained in care, 18% lost-to-follow-up and 1% transferred out. In this study we did not find marital status, gestation age, facility location, ART status at ANC booking, to be associated with loss to follow-up. Conclusion In this study, we found low retention at 3, 6 months and delivery, a threat to elimination of Mother-to-child Transmission of HIV in Zimbabwe. Our findings emphasize the need for enhanced interventions to improve early retention such as post-test counselling, patient tracing and visit reminders.