The lack of accurate population‐based information on childhood cancer stage and survival in low‐income countries is a barrier to improving childhood cancer outcomes. In our study, data from three ...population‐based registries in sub‐Saharan Africa (Abidjan, Harare and Kampala) were examined for children aged under 15. We assessed the feasibility of assigning stage at diagnosis according to Tier 1 of the Toronto Childhood Cancer Stage Guidelines for patients with non‐Hodgkin lymphoma including Burkitt lymphoma (BL), retinoblastoma and Wilms' tumour. Patients were actively followed‐up, allowing calculation of 3‐year relative survival by cancer type and registry. Stage‐specific observed survival was estimated. The cohort comprised 381 children, of whom half (n = 192, 50%) died from any cause within 3 years of diagnosis. Three‐year relative survival varied by malignancy and location and ranged from 17% 95% confidence interval (CI) = 6%‐33% for BL in Harare to 57% (95% CI = 31%‐76%) for retinoblastoma in Kampala. Stage was assigned for 83% of patients (n = 317 of 381), with over half having metastatic or advanced disease at diagnosis (n = 166, 52%). Stage was a strong predictor of survival for each malignancy; for example, 3‐year observed survival was 88% (95% CI = 68%‐96%) and 13% (4%‐29%) for localised and advanced BL, respectively (P < .001). These are the first data on stage distribution and stage‐specific survival for childhood cancers in Africa. They demonstrate the feasibility of the Toronto Stage Guidelines in a low‐resource setting and highlight the value of population‐based cancer registries in aiding our understanding of the poor outcomes experienced by this population.
What's new?
To improve child cancer survival rates in sub‐Saharan Africa, the first step must be to collect accurate data on incidence and survival. The Toronto Stage Guidelines are a tool to internationally standardize the collection of data on stage of diagnosis of childhood cancers. Here, the authors examined data from three population‐based registries on children under 15, and determined that cancer stage at diagnosis was a strong predictor of survival, highlighting the value of population‐based registries. The Toronto Stage Guidelines were shown to be feasible for use in a low‐resource setting to assess cancer stage at diagnosis.
The Prevention of Mother to Child Transmission (PMTCT) of HIV programme in Zimbabwe has had remarkable success despite the country's economic challenges. The aim of this study was to explore the ...challenges faced by breastfeeding mothers on the PMTCT programme.
Narratives from 15 women (age range 19-35 years) were collected at two rural health facilities in Zimbabwe through in-depth interviews over a period of 6 months. Thematic analysis was used to describe breastfeeding mothers' experiences and challenges of being on the PMTCT programme.
The findings suggest that breastfeeding women on the PMTCT programme face challenges that include internal, external and institutional stigma and discrimination. Women reported a sense of powerlessness in decision making on following through with the PMTCT programme and were ambivalent regarding disclosure of their HIV status to their partners and significant others.
HIV and AIDS programmes should pay attention to women's readiness for interventions. There is need to understand women's life experiences to ensure informed and targeted programming for PMTCT.
Viral load (VL) monitoring of pregnant women living with HIV (PWLHIV) and antiretroviral therapy (ART) may contribute to lowering the risk of vertical transmission of HIV. The aims of this study were ...to assess the uptake of HIV VL testing among PWLHIV at entry to the prevention-of-mother-to-child transmission (PMTCT) services and identify facilitatory factors and barriers to HIV VL access.
A retrospective, cross-sectional study was conducted at 15 health facilities in Mutare district, Manicaland Province, Zimbabwe from January to December 2018. This analysis was complemented by prospective interviews with PWLHIV and health care providers between October 2019 and March 2020. Quantitative data were analysed using descriptive and inferential statistical methods. Risk factors were evaluated using multivariate logistic regression. Open-ended questions were analysed and recurring and shared experiences and perceptions of PWLHIV and health care providers identified.
Among 383 PWLHIV, enrolled in antenatal care (ANC) and receiving ART, only 121 (31.6%) had a VL sample collected and 106 (88%) received their results. Among these 106 women, 93 (87.7%) had a VL < 1000 copies/mL and 77 (73%) a VL < 50 copies/mL. The overall median duration from ANC booking to VL sample collection was 87 (IQR, 7-215) days. The median time interval for the return of VL results from date of sample collection was 14 days (IQR, 7-30). There was no significant difference when this variable was stratified by time of ART initiation. VL samples were significantly less likely to be collected at local authority compared to government facilities (aOR = 0.28; 95% CI 0.16-0.48). Barriers to VL testing included staff shortages, non-availability of consumables and sub-optimal sample transportation. Turnaround time was prolonged by the manual results feedback system.
The low rate of HIV VL testing among PWLHIV in Mutare district is a cause for concern. To reverse this situation, the Ministry of Health should consider interventions such as disseminating antiretroviral guidelines and policies electronically, conducting regular PMTCT mentorship for clinical staff members, and utilising point of care testing and telecommunication devices like mHealth to increase uptake of VL testing and improve results turnaround time.
Cancer and sepsis comorbidity is a major public health problem in most parts of the world including Zimbabwe. The microbial aetiologies of sepsis and their antibiograms vary with time and locations. ...Knowledge on local microbial aetiologies of sepsis and their susceptibility patterns is critical in guiding empirical antimicrobial treatment choices.
This was a descriptive cross-sectional study which determined the microbial aetiologies of sepsis from blood cultures of paediatric and adult cancer patients obtained between July 2016 and June 2017. The TDR-X120 blood culture system and TDR 300B auto identification machine were used for incubation of blood culture bottles and identification plus antimicrobial susceptibility testing, respectively.
A total of 142 participants were enrolled; 50 (35.2%) had positive blood cultures, with 56.0% Gram positive, 42.0% Gram-negative bacteria and 2.0% yeast isolated. Common species isolated included coagulase negative Staphylococcus spp. (CoNS) (22.0%), E. coli (16.0%), K. pneumoniae (14.0%), E. faecalis (14.0%) and S. aureus (8.0%). Gram-negative isolates exhibited high resistance to gentamicin (61.9%) and ceftriaxone (71.4%) which are the empiric antimicrobial agents used in our setting. Amikacin and meropenem showed 85.7 and 95.2% activity respectively against all Gram-negative isolates, whilst vancomycin and linezolid were effective against 96.2 and 100.0% of all Gram-positive isolates respectively. We isolated 10 (66.7%) extended spectrum β-lactamase (ESBL) amongst the E. coli and K. pneumoniae isolates. Ten (66.7%) of the Staphylococcus spp. were methicillin resistant.
CoNS, E. coli, K. pneumoniae, E. faecalis and S. aureus were the major microbial drivers of sepsis amongst cancer patients in Zimbabwe. Most isolates were found to be resistant to commonly used empirical antibiotics, with isolates exhibiting high levels of ESBL and methicillin resistance carriage. A nationwide survey on microbial aetiologies of sepsis and their susceptibility patterns would assist in the guidance of effective sepsis empiric antimicrobial treatment among patients with cancer.
PURPOSE Stigma is an understudied barrier to health care acceptance in pediatric oncology. We sought to explore the stigma experience, including its impact on cancer treatment decision making, and ...identify strategies to mitigate stigma for patients with osteosarcoma and retinoblastoma in Guatemala, Jordan, and Zimbabwe. METHODS Participants included caregivers, adolescent patients (age 12-19 years), and health care clinicians. A semistructured interview guide based on The Health Stigma and Discrimination Framework (HSDF) was adapted for use at each site. Interviews were conducted in English, Spanish, Arabic, or Shona, audio-recorded, translated, and transcribed. Thematic analysis focused on stigma practices, experiences, outcomes, drivers, mitigators, and interventions. RESULTS We conducted 56 interviews (28 caregivers, 19 health care clinicians, nine patients; 20 in Guatemala, 21 in Jordan, 15 in Zimbabwe). Major themes were organized into categories used to adapt the HSDF to global pediatric cancer care. Themes were described similarly across all sites, ages, and diagnoses, with specific cultural nuances noted. Pediatric cancer stigma was depicted as an isolating and emotional experience beginning at diagnosis and including internalized and associative stigma. Stigma affected decision making and contributed to negative outcomes including delayed diagnosis, treatment abandonment, regret, and psychosocial fragility. Overcoming stigma led to positive outcomes including resilience, treatment adherence, pride, and advocacy. Identified stigma drivers and mitigators were linked to potential interventions. CONCLUSION Participants describe a shared stigma experience that transcends geography, cultural context, age, and diagnosis. Stigma manifestations have the potential to impact medical decision making and affect long-term psychological outcomes. Stigma assessment tools and interventions aimed at stigma mitigation including educational initiatives and support groups specific to pediatric cancer should be the focus of future research.
Stigma affects patients with pediatric cancer around the world, transcending cultural differences and affecting care.
Background: Poor retention in the prevention of women in prevention of vertical transmission programs remains a formidable common setback in elimination of HIV/AIDS. It creates new problems such as ...poor health outcomes and increased incidence of vertical transmission of HIV. There is a dearth of qualitative information to explain poor retention of women in prevention of mother-to-child transmission (PMTCT) programs in Zimbabwe. The purpose of the study was to explore the enablers and barriers of retention of women in PMTCT programs. Methods: This was a basic qualitative study conducted at four health centers in Zimbabwe. Four audiotaped focus group discussions were conducted with 34 pregnant or breastfeeding women coming for PMTCT services at the health centers. Descriptive statistics was used for sample demographics. Transcripts were analyzed through latent content analysis based on the Graneheim and Lundman method. Results: Maternal determination, a four-tier support system, and an inspiring health package were enablers to retention in the PMTCT program while uninspired individual engagement, paternalism, and undesirable PMTCT-related events were barriers to retention of women in the PMTCT program. Conclusions: Reinforcing hope for the women and their children, active management of side effects of antiretroviral medicine, consistent peer support, enhancing confidentiality among community cadres, and commitment from community or religious leaders may improve retention of women in PMTCT programs; for women with HIV during pregnancy, delivery and post-natal care.
We examined trends in childhood cancer incidence in sub‐Saharan Africa using data from two population‐based cancer registries in Harare (Zimbabwe) and Kyadondo (Uganda) with cases classified ...according to the International Classification of Childhood Cancer and explored reasons for observed variations and changes. Over the whole 25‐year period (1991‐2015) studied, there were only small, and nonsignificant overall trends in incidence. Nevertheless, within the period, peaks in incidence occurred from 1996 to 2001 in Harare (Zimbabwe) and from 2003 to 2006 in Kyadondo (Uganda). Kaposi sarcoma and non‐Hodgkin lymphoma accounted for the majority of the cases during these periods. These fluctuations in incidence rates in both registries can be linked to similar trends in the prevalence of HIV, and the availability of antiretroviral therapy. In addition, we noted that, in Harare, incidence rates dropped from 2003 to 2004 and 2007 to 2008, correlating with declines in national gross domestic product. The results indicate that the registration of childhood cancer cases in resource‐poor settings is linked to the availability of diagnostic services mediated by economic developments. The findings highlight the need for specialised diagnostic and treatment programmes for childhood cancer patients as well as positive effects of HIV programmes on certain childhood cancers.
What's new?
These authors tracked childhood cancer rates in sub‐Saharan Africa over a 25‐year period, from 1991 to 2015. They analyzed data collected in Harare, Zimbabwe, and Kyadondo, Uganda. Compared with high‐income countries, these regions had markedly lower rates of childhood cancers, particularly leukemia. The incidence did not trend upward or downward overall, but peaks in incidence corresponded with HIV prevalence, while dips coincided with decline in national GDP, when families might be unable to afford consultation and treatment. This data suggests it will be challenging to meet the WHO's target of over 60% childhood cancer survival by 2030.
We examined trends in childhood cancer incidence in sub‐Saharan Africa using data from two population‐based cancer registries in Harare (Zimbabwe) and Kyadondo (Uganda) with cases classified ...according to the International Classification of Childhood Cancer and explored reasons for observed variations and changes. Over the whole 25‐year period (1991‐2015) studied, there were only small, and nonsignificant overall trends in incidence. Nevertheless, within the period, peaks in incidence occurred from 1996 to 2001 in Harare (Zimbabwe) and from 2003 to 2006 in Kyadondo (Uganda). Kaposi sarcoma and non‐Hodgkin lymphoma accounted for the majority of the cases during these periods. These fluctuations in incidence rates in both registries can be linked to similar trends in the prevalence of HIV, and the availability of antiretroviral therapy. In addition, we noted that, in Harare, incidence rates dropped from 2003 to 2004 and 2007 to 2008, correlating with declines in national gross domestic product. The results indicate that the registration of childhood cancer cases in resource‐poor settings is linked to the availability of diagnostic services mediated by economic developments. The findings highlight the need for specialised diagnostic and treatment programmes for childhood cancer patients as well as positive effects of HIV programmes on certain childhood cancers.
Introduction
The Collaborative Wilms Tumour (WT) Africa Project implemented an adapted WT treatment guideline in six centres in sub‐Saharan Africa. The primary objectives were to describe abandonment ...of treatment, death during treatment, event‐free survival (EFS) and relapse following implementation. An exploratory objective was to compare outcomes with the baseline evaluation, a historical cohort preceding implementation.
Methods
The Collaborative WT Africa Project is a multi‐centre prospective clinical trial that began in 2014. Funding was distributed to all participating centres and used to cover treatment, travel and other associated costs for patients. Patient characteristics, tumour characteristics and events were described.
Results
In total, 201 WT patients were included. Two‐year EFS was 49.9 ± 3.8% when abandonment of treatment was considered an event. Relapse of disease occurred in 21% (42 of 201) of all included patients and in 26% (42 of 161) of those who had a nephrectomy. Programme implementation was associated with significantly higher survival without evidence of disease at the end of treatment (52% vs 68.5%, P = .002), significantly reduced abandonment of treatment (23% vs 12%, P = .009) and fewer deaths during treatment (21% vs 13%, P = .06).
Conclusion
This collaborative implementation of an adapted WT treatment guideline, using relatively simple and low‐cost interventions, was feasible. Two‐year EFS was almost 50%. In addition, a significant decrease in treatment abandonment and an increase in survival at the end of treatment were observed compared to a pre‐implementation cohort. Future work should focus on decreasing deaths during treatment and will include enhancing supportive care.
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