• Delivering HIV Care in Challenging Operating Environments: The MSF Experience Towards Differentiated Models of Care for Settings with Multiple Basic Health Care Needs

      Ssonko, C; Gonzalez, L; Mesic, A; da Fonseca, M; Achar, J; Safar, N; Martin, B; Wong, S; Casas, E (International AIDS Society, 2017-07-21)
      Introduction: Countries in the West and Central African regions struggle to offer quality HIV care at scale, despite HIV prevalence being relatively low. In these challenging operating environments, basic health care needs are multiple, systems are highly fragile and conflict disrupts health care. Médecins Sans Frontières (MSF) has been working to integrate HIV care in basic health services in such settings since 2000. We review the implementation of differentiated HIV care and treatment approaches in MSF-supported programmes in South Sudan (RoSS), Central African Republic (CAR) and Democratic Republic of Congo (DRC). Methods: A descriptive analysis from CAR, DRC and RoSS programmes reviewing methodology and strategies of HIV care integration between 2010 and 2015 was performed. We describe HIV care models integrated within the provision of general health care and highlight best practices and challenges. Results: Services included provision of general health care, with out-patient care (range between countries 43,343 and 287,163 consultations/year in 2015) and in-patient care (range 1076–16,595 in 2015). By the end of 2015 antiretroviral therapy (ART) initiations reached 12–255 patients/year. A total of 1101 and 1053 patients were on ART in CAR and DRC, respectively. In RoSS 186 patients were on ART when conflict recommenced late in 2013. While ART initiation and monitoring were mostly clinically driven in the early phase of the programmes, DRC implemented CD4 monitoring and progressively HIV viral load (VL) monitoring during study period. Attacks to health care facilities in CAR and RoSS disrupted service provision temporarily. Programmatic challenges include: competing health priorities influencing HIV care and need to integrate within general health services. Differentiated care approaches that support continuity of care in these programmes include simplification of medical protocols, multi-month ART prescriptions, and community strategies such as ART delivery groups, contingency plans and peer support activities. Conclusions: The principles of differentiated HIV care for high-quality ART delivery can successfully be applied in challenging operating environments. However, success heavily depends on specific adaptations to each setting.
    • 'He who helps the guilty, shares the crime'? INGOs, moral narcissism and complicity in wrongdoing

      Buth, P; de Gryse, B; Healy, S; Hoedt, V; Newell, T; Pintaldi, G; Del Valle, H; Sheather, JC; Wong, S (BMJ Publishing Group, 2018-03-17)
      Humanitarian organisations often work alongside those responsible for serious wrongdoing. In these circumstances, accusations of moral complicity are sometimes levelled at decision makers. These accusations can carry a strong if unfocused moral charge and are frequently the source of significant moral unease. In this paper, we explore the meaning and usefulness of complicity and its relation to moral accountability. We also examine the impact of concerns about complicity on the motivation of humanitarian staff and the risk that complicity may lead to a retreat into moral narcissism. Moral narcissism is the possibility that where humanitarian actors inadvertently become implicated in wrongdoing, they may focus more on their image as self-consciously good actors than on the interests of potential beneficiaries. Moral narcissism can be triggered where accusations of complicity are made and can slew decision making. We look at three interventions by Médecins Sans Frontières that gave rise to questions of complicity. We question its decision-guiding usefulness. Drawing on recent thought, we suggest that complicity can helpfully draw attention to the presence of moral conflict and to the way International Non-Governmental Organisations (INGOs) can be drawn into unintentional wrongdoing. We acknowledge the moral challenge that complicity presents to humanitarian staff but argue that complicity does not help INGOs make tough decisions in morally compromising situations as to whether they should continue with an intervention or pull out.
    • Hepatitis E should be considered a neglected tropical disease.

      Asman, AS; Ciglenecki, I; Wamala, JF; Lynch, J; Aggarwal, R; Rahman, M; Wong, S; Serafini, M; Moussa, AM; Dalton, HR; et al. (Public Library of Science, 2019-07-25)
    • High prevalence of ESBL-positive bacteria in an obstetrics emergency hospital and neonatal care unit—Haiti, 2016

      Chaintarli, K; Lenglet, A; Beauzile, BD; Senat-Delva, R; Mabou, MM; Martino, C; Berthet, M; Wong, S; Hopman, J (The Society for Healthcare Epidemiology of America, 2018-08-30)
      Patient colonization with extended-spectrum β-lactamase–producing gram-negative bacteria (ESBL-GNB) could serve as a potential reservoir for transmission of multidrug-resistant (MDR) bacteria in a hospital setting. Individuals colonized with ESBLEnterobacteriaceae are also known to be at a higher risk of ESBLGNB infection following their colonization.1 We encountered an outbreak of MDR Klebsiella pneumoniae in the neonatal care unit (NCU) of the Médecins Sans Frontiéres (MSF) obstetric emergency hospital in Port au Prince (CRUO), Haiti, between 2014 and 2015.2 As part of ongoing surveillance activities for MDR bacteria and in an effort to better target infection, prevention, and control (IPC) measures throughout the hospital, we conducted a point-prevalence survey to estimate the prevalence of colonization with ESBL-GNB and to identify risk factors for colonization with ESBL-GNB in women and neonates admitted to this hospital.
    • Inclusion of Real-Time Hand Hygiene Observation and Feedback in a Multimodal Hand Hygiene Improvement Strategy in Low-Resource Settings.

      Lenglet, A; van Deursen, B; Viana, R; Abubakar, N; Hoare, S; Murtala, A; Okanlawon, M; Osatogbe, J; Emeh, V; Gray, N; et al. (JAMA, 2019-08-02)
      IMPORTANCE: Hand hygiene adherence monitoring and feedback can reduce health care-acquired infections in hospitals. Few low-cost hand hygiene adherence monitoring tools exist in low-resource settings. OBJECTIVE: To pilot an open-source application for mobile devices and an interactive analytical dashboard for the collection and visualization of health care workers' hand hygiene adherence data. DESIGN, SETTING, AND PARTICIPANTS: This prospective multicenter quality improvement study evaluated preintervention and postintervention adherence with the 5 Moments for Hand Hygiene, as suggested by the World Health Organization, among health care workers from April 23 to May 25, 2018. A novel data collection form, the Hand Hygiene Observation Tool, was developed in open-source software and used to measure adherence with hand hygiene guidelines among health care workers in the inpatient therapeutic feeding center and pediatric ward of Anka General Hospital, Anka, Nigeria, and the postoperative ward of Noma Children's Hospital, Sokoto, Nigeria. Qualitative data were analyzed throughout data collection and used for immediate feedback to staff. A more formal analysis of the data was conducted during October 2018. EXPOSURES: Multimodal hand hygiene improvement strategy with increased availability and accessibility of alcohol-based hand sanitizer, staff training and education, and evaluation and feedback in near real-time. MAIN OUTCOMES AND MEASURES: Hand hygiene adherence before and after the intervention in 3 hospital wards, stratified by health care worker role, ward, and moment of hand hygiene. RESULTS: A total of 686 preintervention adherence observations and 673 postintervention adherence observations were conducted. After the intervention, overall hand hygiene adherence increased from 32.4% to 57.4%. Adherence increased in both wards in Anka General Hospital (inpatient therapeutic feeding center, 24.3% [54 of 222 moments] to 63.7% [163 of 256 moments]; P < .001; pediatric ward, 50.9% [132 of 259 moments] to 68.8% [135 of 196 moments]; P < .001). Adherence among nurses in Anka General Hospital also increased in both wards (inpatient therapeutic feeding center, 17.7% [28 of 158 moments] to 71.2% [79 of 111 moments]; P < .001; pediatric ward, 45.9% [68 of 148 moments] to 68.4% [78 of 114 moments]; P < .001). In Noma Children's Hospital, the overall adherence increased from 17.6% (36 of 205 moments) to 39.8% (88 of 221 moments) (P < .001). Adherence among nurses in Noma Children's Hospital increased from 11.5% (14 of 122 moments) to 61.4% (78 of 126 moments) (P < .001). Adherence among Noma Children's Hospital physicians decreased from 34.2% (13 of 38 moments) to 8.6% (7 of 81 moments). Lowest overall adherence after the intervention occurred before patient contact (53.1% [85 of 160 moments]), before aseptic procedure (58.3% [21 of 36 moments]), and after touching a patient's surroundings (47.1% [124 of 263 moments]). CONCLUSIONS AND RELEVANCE: This study suggests that tools for the collection and rapid visualization of hand hygiene adherence data are feasible in low-resource settings. The novel tool used in this study may contribute to comprehensive infection prevention and control strategies and strengthening of hand hygiene behavior among all health care workers in health care facilities in humanitarian and low-resource settings.
    • Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan

      Älgå, A; Wong, S; Shoaib, M; Lundgren, K; Giske, CG; Von Schreeb, J; Malmstedt, J (BioMed Central, 2018-05-22)
      Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared.
    • A Medecins Sans Frontieres Ethics Framework for Humanitarian Innovation Plus Worked Case Studies

      Sheather, J; Jobanputra, K; Schopper, D; Pringle, J; Venis, S; Wong, S; Vincent-Smith, R (2016-10)
    • A Médecins Sans Frontières Ethics Framework for Humanitarian Innovation

      Sheather, J; Jobanputra, K; Schopper, D; Pringle, J; Venis, S; Wong, S; Vincent-Smith, R (Public Library of Medicine (PLoS), 2016-09-06)
      Kiran Jobanputra and colleagues describe an ethics framework to support the ethics oversight of innovation projects in medical humanitarian contexts.
    • Myocardial and Haemodynamic Responses to Two Fluid Regimens in African Children with Severe Malnutrition and Hypovolaemic Shock (AFRIM study)

      Obonyo, N; Brent, B; Olupot-Olupot, P; Boele van Hensbroek, M; Kuipers, I; Wong, S; Shiino, K; Chan, J; Fraser, J; van Woensel, JBM; et al. (Elsevier, 2017-05-03)
      Fluid therapy in severely malnourished children is hypothesized to be deleterious owing to compromised cardiac function. We evaluated World Health Organization (WHO) fluid resuscitation guidelines for hypovolaemic shock using myocardial and haemodynamic function and safety endpoints.
    • Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial

      Älgå, A; Haweizy, R; Bashaireh, K; Wong, S; Lundgren, KC; von Schreeb, J; Malmstedt, J (Elsevier, 2020-03-01)
      Background: In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment. Methods: In this pragmatic, randomised, controlled superiority trial done at two civilian hospitals in Jordan and Iraq, we recruited patients aged 18 years or older, presenting with a conflict-related extremity wound within 72 h after injury. Participants were assigned (1:1) to receive either NPWT or standard treatment. We used a predefined, computer-generated randomisation list with three block sizes. Participants and their treating physicians were not masked to treatment allocation. The primary endpoint was wound closure by day 5. The coprimary endpoint was net clinical benefit, defined as a composite of wound closure by day 5 and freedom from any bleeding, wound infection, sepsis, or amputation of the index limb. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT02444598, and is closed to accrual. Findings: Between June 9, 2015, and Oct 24, 2018, 174 patients were randomly assigned to either the NPWT group (n=88) or the standard treatment group (n=86). Five patients in the NPWT group and four in the standard treatment group were excluded from the intention-to-treat analysis. By day 5, 41 (49%) of 83 participants in the NPWT group and 49 (60%) of 82 participants in the standard treatment group had closed wounds, with an absolute difference of 10 percentage points (95% CI -5 to 25, p=0·212; risk ratio [RR] 0·83, 95% CI 0·62 to 1·09). Net clinical benefit was seen in 33 (41%) of 81 participants in the NPWT group and 34 (44%) of 78 participants in the standard treatment group, with an absolute difference of 3 percentage points (95% CI -12 to 18, p=0·750; RR 0·93, 95% CI 0·65 to 1·35). There was one in-hospital death in the standard treatment group and none in the NPWT group. The proportion of participants with sepsis, bleeding leading to blood transfusion, and limb amputation did not differ between groups. Interpretation: NPWT did not yield superior clinical outcomes compared with standard treatment for acute conflict-related extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence. Funding: The Stockholm County Council, the Swedish National Board of Health and Welfare, and Médecins Sans Frontières.
    • Perceptions of Healthcare-Associated Infection and Antibiotic Resistance among Physicians Treating Syrian Patients with War-Related Injuries

      Älgå, A; Karlow Herzog, K; Alrawashdeh, M; Wong, S; Khankeh, H; Stålsby Lundborg, C (MDPI, 2018-12-01)
      Healthcare-associated infections (HAIs) constitute a major contributor to morbidity and mortality worldwide, with a greater burden on low- and middle-income countries. War-related injuries generally lead to large tissue defects, with a high risk of infection. The aim of this study was to explore how physicians in a middle-income country in an emergency setting perceive HAI and antibiotic resistance (ABR). Ten physicians at a Jordanian hospital supported by Médecins Sans Frontières were interviewed face-to-face. The recorded interviews were transcribed verbatim and analyzed by qualitative content analysis with an inductive and deductive approach. The participants acknowledged risk factors of HAI and ABR development, such as patient behavior, high numbers of injured patients, limited space, and non-compliance with hygiene protocols, but did not express a sense of urgency or any course of action. Overuse and misuse of antibiotics were reported as main contributors to ABR development, but participants expressed no direct interrelationship between ABR and HAI. We conclude that due to high patient load and limited resources, physicians do not see HAI as a problem they can prioritize. The knowledge gained by this study could provide insights for the allocation of resources and development of hygiene and wound treatment protocols in resource-limited settings.
    • "Reality rarely looks like the guidelines": a qualitative study of the challenges hospital-based physicians encounter in war wound management

      Älgå, A; Karlow Herzog, K; Alrawashdeh, M; Wong, S; Khankeh, H; Stålsby Lundborg, C (BioMed Central, 2018-06-27)
      Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use.