Assessing the quality of the management skills required for lower respiratory tract infections in Kilimanjaro, Tanzania

Bernard Mbwele

1Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania;ART Project, Christian Social Service Commission, CSSC, Mwanza, Tanzania.

DOI: 10.4236/health.2014.61004                

Abstract

Background: Lower respiratory tract infections (LRTI) are among the leading causes of morbidity and mortality. A severe form of atypical pneumonia, Q fever, has been found in Northern Tanzania. Assessment of the quality of health care for lower respiratory tract infection from the clinicians’ performance has rarely been performed. Methods: A cross sectional descriptive study using the qualitative and quantitative approaches for assessing clinicians and patient files from 11 health facilities of Kilimanjaro region. The facilities were of 4 different levels of public health care delivery and 1 private independent hospital. Results: Medications for LRTI were highly variable in 346 files and from attempts of treatment reported in 53 clinician’s interviews. No file showed attempts for assessing the severity of Pneumonia. Only 6 (11.1%) clinicians could mention causes of atypical pneumonia. Only 7 clinicians (13.0%) were aware of Q-fever and could mention the cause. The quality of clinical records for monitoring the progress was not the same in all levels of care and the difference in availability was statistically significant as level of mental state χ2 (4) = 139.4; P value < 0.001, blood pressure χ2 (8) = 75.2; P value < 0.001, temperature χ2 (4) = 78.7; P value < 0.001, pulse rate χ2 (4) = 139.1; P value < 0.001, respiratory rate χ2 (4) = 197.7; P value < 0.001, auscultation χ2 (4) = 92.2; P value < 0.001. Conclusion: National guidelines for LRTI in Tanzania shall include severity assessments and how to rule out atypical pneumonia using evidence base approaches.

Keywords

Quality; Health Care; Lower Respiratory Tract Infections; Tanzania; Sub-Saharan Africa

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Lozano, R., Naghavi, M., Foreman, K., Lim, S., Shibuya, K., et al. (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380, 2095-2128. http://dx.doi.org/10.1016/S0140-6736(12)61728-0
[2]	Murray, C.J. and Lopez, A.D. (1996) Evidence-based health policy—Lessons from the Global Burden of Disease Study. Science, 274, 740-743. http://dx.doi.org/10.1126/science.274.5288.740
[3]	Michaud, C.M., Murray, C.J. and Bloom, B.R. (2001) Burden of disease—Implications for future research. JAMA, 285, 535-539. http://dx.doi.org/10.1001/jama.285.5.535
[4]	Bates, M., Mudenda, V., Mwaba, P. and Zumla, A. (2013) Deaths due to respiratory tract infections in Africa: A review of autopsy studies. Current Opinion in Pulmonary Medicine, 19, 229-237. http://dx.doi.org/10.1097/MCP.0b013e32835f4fe4
[5]	Beaglehole, R. (2004) The World Health Report 2004— Changing History. Geneva, 120-124.
[6]	Sligl, W.I. and Marrie, T.J. (2013) Severe community-acquired pneumonia. Critical Care Clinics, 29, 563-601. http://dx.doi.org/10.1016/j.ccc.2013.03.009
[7]	Mizgerd, J.P. (2006) Lung infection—A public health priority. PLOS Medicine, 3, e76. http://dx.doi.org/10.1371/journal.pmed.0030076
[8]	Mathers, C.D., Boerma, T. and Ma Fat, D. (2009) Global and regional causes of death. British Medical Bulletin, 92, 7-32. http://dx.doi.org/10.1093/bmb/ldp028
[9]	Hoffken, G., Lorenz, J., Kern, W., Welte, T., Bauer, T., et al. (2010) Guidelines for the epidemiology, diagnosis, antimicrobial therapy and management of community-acquired pneumonia and lower respiratory tract infections in adults. Deutsche Medizinische Wochenschrift, 135, 359-365.
[10]	Feldman, C. and Anderson, R. (2013) HIV-associated bacterial pneumonia. Clinics in Chest Medicine, 34, 205-216. http://dx.doi.org/10.1016/j.ccm.2013.01.006
[11]	Feldman, C. and Anderson, R. (2012) Antibiotic resistance of pathogens causing community-acquired pneumonia. Seminars in Respiratory and Critical Care Medicine, 33, 232-243. http://dx.doi.org/10.1055/s-0032-1315635
[12]	Mudhune, S. and Wamae, M. (2009) Network surveillance for pneumococcal disease in the East African Region. Report on invasive disease and meningitis due to Haemophilus influenzae and Streptococcus pneumonia from the network for surveillance of pneumococcal disease in the East African Region. Clinical Infectious Diseases, 48, S147-S152. http://dx.doi.org/10.1086/596494
[13]	Mandell, L.A., Wunderink, R.G., Anzueto, A., Bartlett, J.G., Campbell, G.D., et al. (2007) Infectious diseases society of America/American thoracic society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical Infectious Diseases, 44, S27-S72. http://dx.doi.org/10.1086/511159
[14]	Macfarlane, J.T. and Boldy, D. (2004) 2004 update of BTS pneumonia guidelines: What’s new? Thorax, 59, 364-366. http://dx.doi.org/10.1136/thx.2004.024992
[15]	Menendez, R., Torres, A., Aspa, J., Capelastegui, A., Prat, C., et al. (2010) Community acquired pneumonia. New guidelines of the Spanish Society of Chest Diseases and Thoracic Surgery (SEPAR). Archivos de Bronconeumología, 46, 543-558. http://dx.doi.org/10.1016/S1579-2129(11)60008-6
[16]	American Thoracic Society (2005) Guidelines for the management of adults with hospital-acquired, ventilatorassociated, and healthcare-associated pneumonia. American Journal of Respiratory and Critical Care Medicine, 171, 388-416. http://dx.doi.org/10.1164/rccm.200405-644ST
[17]	Working Group of the South African Thoracic Society (2007) Management of community-acquired pneumonia in adults. South African Medical Journal, 97, 1295-1306.
[18]	Heppner, H.J., Sehlhoff, B., Niklaus, D., Pientka, L. and Thiem, U. (2011) Pneumonia severity index (PSI), CURB-65, and mortality in hospitalized elderly patients with aspiration pneumonia. Zeitschrift für Gerontologie und Geriatrie, 44, 229-234. http://dx.doi.org/10.1007/s00391-011-0184-3
[19]	Cunha, B.A. (2006) The atypical pneumonias: Clinical diagnosis and importance. Clinical Microbiology and Infection, 12, 12-24. http://dx.doi.org/10.1111/j.1469-0691.2006.01393.x
[20]	Hartung, T.K., Chimbayo, D., van Oosterhout, J.J., Chikaonda, T., van Doornum, G.J., et al. (2011) Etiology of suspected pneumonia in adults admitted to a high-dependency unit in Blantyre, Malawi. American Society of Tropical Medicine and Hygiene, 85, 105-112. http://dx.doi.org/10.4269/ajtmh.2011.10-0640
[21]	Kim, C., Nyoka, R., Ahmed, J.A., Winchell, J.M., Mitchell, S.L., et al. (2012) Epidemiology of respiratory infections caused by atypical bacteria in two Kenyan refugee camps. Journal of Immigrant and Minority Health, 14, 140-145. http://dx.doi.org/10.1007/s10903-011-9494-1
[22]	Prabhu, M., Nicholson, W.L., Roche, A.J., Kersh, G.J., Fitzpatrick, K.A., et al. (2011) Q fever, spotted fever group, and typhus group rickettsioses among hospitalized febrile patients in northern Tanzania. Clinical Infectious Diseases, 53, e8-e15. http://dx.doi.org/10.1093/cid/cir411
[23]	Cunha, B.A., Pherez, F. and Walls, N. (2009) Severe cytomegalovirus (CMV) community-acquired pneumonia (CAP) in a nonimmunocompromised host. Heart Lung, 38, 243-248. http://dx.doi.org/10.1016/j.hrtlng.2008.05.008
[24]	Kibiki, G.S., Mulder, B., van der Ven, A.J., Sam, N., Boeree, M.J., et al. (2007) Laboratory diagnosis of pulmonary tuberculosis in TB and HIV endemic settings and the contribution of real time PCR for M. tuberculosis in bronchoalveolar lavage fluid. Tropical Medicine & International Health, 12, 1210-1217. http://dx.doi.org/10.1111/j.1365-3156.2007.01907.x
[25]	Semvua, H.H. and Kibiki, G.S. (2011) AtriplaR/anti-TB combination in TB/HIV patients. Drug in focus. BMC Research Notes, 4, 511. http://dx.doi.org/10.1186/1756-0500-4-511
[26]	Kabali, C., von Reyn, C.F., Brooks, D.R., Waddell, R., Mtei, L., et al. (2011) Completion of isoniazid preventive therapy and survival in HIV-infected, TST-positive adults in Tanzania. International Journal of Tuberculosis and Lung Disease, 15, 1515-1521. http://dx.doi.org/10.5588/ijtld.10.0788
[27]	Thiem, U., Heppner, H.J. and Pientka, L. (2011) Elderly patients with community-acquired pneumonia: Optimal treatment strategies. Drugs Aging, 28, 519-537. http://dx.doi.org/10.2165/11591980-000000000-00000
[28]	Wiersinga, W.J., Bonten, M.J., Boersma, W.G., Jonkers, R.E., Aleva, R.M., et al. (2012) SWAB/NVALT (Dutch Working Party on Antibiotic Policy and Dutch Association of Chest Physicians) guidelines on the management of community-acquired pneumonia in adults. Netherlands Journal of Medicine, 70, 90-101.
[29]	Watkins, R.R. and Lemonovich, T.L. (2011) Diagnosis and management of community-acquired pneumonia in adults. American Family Physician, 83, 1299-1306.
[30]	Arnold, F.W., La Joie, A.S., Brock, G.N., Peyrani, P., Rello, J., et al. (2009) Improving outcomes in elderly patients with community-acquired pneumonia by adhering to national guidelines: Community-Acquired Pneumonia Organization International cohort study results. Archives of Internal Medicine, 169, 1515-1524. http://dx.doi.org/10.1001/archinternmed.2009.265
[31]	Menendez, R., Ferrando, D., Valles, J.M. and Vallterra, J. (2002) Influence of deviation from guidelines on the outcome of community-acquired pneumonia. Chest, 122, 612-617. http://dx.doi.org/10.1378/chest.122.2.612
[32]	Nyamande, K. and Lalloo, U.G. (2007) Poor adherence to South African guidelines for the management of community-acquired pneumonia. South African Medical Journal, 97, 601-603.
[33]	Ministry of Health and Social Welfare, The Government of Tanzania (2007) Standard Treatment Guidelines (STG) and the National Essential Medicines List (NEMLIT) for mainland Tanzania. Dar es Salaam.
[34]	National Tuberculosis and Leprosy Control Programme, NTLP (2008) Management of TB/HIV co-infected patients Manual for Health Care Workers at TB clinics and HIV Care & Treatment Centers. Ministry of Health and Social Welfare, Dar es Salaam.
[35]	Ntuli, A.K., Kabengula, J.S. and Msuya, S.E. (2011) Perceived barriers and attitudes of health care providers towards Provider-Initiated HIV Testing and Counseling in Mbeya region, southern highland zone of Tanzania. Pan African Medical Journal, 8, 17.
[36]	Tribble, A.C., Hamilton, C.D., Crump, J.A., Mgonja, A., Mtalo, A., et al. (2009) Missed opportunities for diagnosis of tuberculosis and human immunodeficiency virus co-infection in Moshi, Tanzania. International Journal of Tuberculosis and Lung Disease, 13, 1260-1266.