Epidemiology and Biostatistics

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Browsing Epidemiology and Biostatistics by browse.metadata.advisor "Chikte, Usuf M. E."

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    An evaluation of the effectiveness of task-shifting health systems approaches, including community-based and pharmaceutical care models, for HIV treatment and prevention programs in South Africa
    (Stellenbosch : Stellenbosch University, 2020-12) Fatti, Geoffrey; Chikte, Usuf M. E.; Nachega, Jean; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
    ENGLISH SUMMARY : Southern Africa is the epicenter of the human immunodeficiency virus (HIV) pandemic having the highest burden of HIV globally. Although South Africa has made great strides with the roll-out of its antiretroviral treatment (ART) program, ongoing challenges include high attrition of patients from ART care and ongoing elevated HIV incidence. There is also a severe shortage of professional health workers in the region, which impacts HIV program delivery. Task-shifting health systems approaches have been developed in order for the health system to provide large-scale HIV program delivery with limited numbers of professional health workers. This thesis evaluates the effectiveness of task-shifting health systems interventions in HIV prevention and treatment programs in South Africa, including community-based programs utilizing community healthcare workers (CHWs), and pharmaceutical care models. Data were collected in cohort studies conducted between 2004 and 2015/2016 in four provinces of South Africa. The results chapters of the thesis are presented in the form of published papers. The first paper evaluates the effectiveness of a community-based support (CBS) program amongst a large cohort of adults living with HIV receiving ART up to five years after ART initiation. Adults who received CBS had improved ART outcomes, including improved patient retention with lower loss to follow-up and lower mortality, both of which were reduced by one third. The second paper evaluates the effectiveness of a community-based combination HIV prevention intervention delivered by CHWs for pregnant and postpartum women in a high HIV incidence district in KwaZulu-Natal. Maternal HIV incidence amongst participants who received the intervention was considerably lower compared to other studies from the region. The paper further recommends expanded roll-out of home-based couples HIV counselling and testing, and initiating oral pre-exposure prophylaxis for HIV particularly for pregnant women within serodiscordant couples, in order to reduce maternal HIV incidence. The third paper compares the effectiveness and cost of two task-shifting pharmaceutical care models for ART delivery in South Africa, namely the indirectly supervised pharmacist assistant (ISPA) model and the nurse-managed model. The ISPA model was found to have a higher quality of pharmaceutical care, was less costly to implement and was possibly associated with improved patient clinical outcomes. The fourth paper evaluates the effectiveness and cost-effectiveness of CBS for adolescents and youth receiving ART at 47 health facilities in South Africa. CBS was found to substantially reduce patient attrition from ART care in adolescents and youth, and was a low cost intervention with reasonable cost-effectiveness. Lastly, a published scientific letter is included as an appendix, which is a critique of findings from a cluster-randomized trial investigating the effectiveness of two interventions as part of the current South African National Adherence guidelines (AGL). The letter recommends the inclusion of long-term CBS for ART patients utilizing CHWs in a revised version of the AGL. The thesis concludes that task-shifting healthcare models including communitybased and pharmaceutical care models are effective and cost-efficient for HIV program delivery in South Africa, and can aid the greater Southern African regions’ progress toward several of the interrelated UNAIDS Sustainable Development Goals by 2030.
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    Mechanical debridement with antibiotics in the treatment of chronic periodontitis : effect on systemic biomarkers : a systematic review
    (Stellenbosch : Stellenbosch University, 2019-04) Munasur, Sudhir L.; Chikte, Usuf M. E.; Turawa, Eunice B.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
    ENGLISH SUMMARY : Background: Chronic periodontitis is an inflammatory oral disease which leads to the destruction of the supporting tissues of the teeth, leading to bone resorption and tooth loss. Destruction of the periodontal attachment apparatus can result in gingival recession and root furcation exposure in advanced stages resulting in tooth mobility and tooth loss. Mechanical debridement is the most frequent treatment for chronic periodontitis, in severe cases systemic antibiotics in conjunction with mechanical debridement have been used. The efficacy and the beneficial effect of this combination on the inflammatory biomarkers require further investigation. Objectives: The aim of this systematic review was to assess the effectiveness of adjunctive antibiotics in the improvement of inflammatory systemic biomarkers in the treatment chronic periodontitis. Search methods: We searched the following electronic databases: Cochrane Oral Health Group Trials Register (30th June 2018). The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2018 – current issue), MEDLINE (1966 to present), EMBASE (1982 to present), CINAHL via EBSCO (1990 -present), Google scholar (1990 - present). Web of Knowledge (1990 to May 2018), The meta-Register of Controlled Trials (www.controlled-trials.com), The US National Institutes of Health On-going Trials Register (www.clinicaltrials.gov). The World Health Organization International Clinical Trials Registry platform (www.who.int/trialsearch) was searched to identify relevant trials for inclusion in the review. Conference proceedings, on-going trials registers (02/06/2018) and reference list of included articles were assessed for relevant trials. No language or date of publication restrictions applied. Selection criteria: We searched for randomised controlled trials (RCTs that evaluated the effectiveness of adjunct antibiotic therapy on the systemic biomarkers in the treatment of chronic periodontitis. All trials that compared adjunctive systemic antibiotics with mechanical debridement or mechanical debridement alone, or scaling and root planning, oral hygiene and prophylaxis or placebo were included in the study. Data collection and analysis: Two reviewers independently examined the titles and abstracts retrieved by the search to identify relevant trials for inclusion in the review. All included trials were assessed for risk of bias and data were extracted for further analysis. The primary outcomes assessed include: changes in serum/blood levels of inflammatory biomarkers such as Matrix Metalloproteinases (MMPs), Tissue Inhibitors of MMPs(TIMs), Cytokines, C-Reactive Protein(CRP) and Glycated haemoglobin(HbA1c). Secondary outcomes include periodontal indices such as bleeding on probing (BOP), gingival index (GI), clinical attachment level (CAL), plaque index (PI) and probing pocket depth (PPD). Main results: Fourteen trials (n=1457 participants) were included in the review. Seven trials reported on MMP-8, with average of 3 months time to event. Five trials reported on IL-1β, three trials on IL-6 and two on IL-8 serum level. Four trials reported on CRP; while eight reported on HbA1c level and one on TIMP-1 level. Trials were assessed for risk of bias and judged as low, high, or unclear of risk of bias. Six studies showed no significant differences in MMP-8 concentration level between the two intervention groups. Significant decrease (60%) in odds of increased MMP-8 levels during 2-year study was reported in one trial (OR 0.40, 95%CI: 0.21 to 0.77, p=0.006). One study reported no significant difference for TIMP-1 (0.96, 95% CI: 0.78 to 1.18, p=0.7), while two studies showed significant reduction in HbA1c (10%) at 3 months. Other studies reported no difference in HbA1c levels (%): (Mean (SD) 7.00 (0.76) versus 7.11 (0.99); p=0.710), (Median (Interquartile Range [IQR]) 6.3 (5.5,7.3) versus 6.7 (6.3, 7.7); p=0.8), (p=0.35, 0.55, 0.33, and 0.62, at baseline, 3 months, 6 months, and after 1 year of treatment respectively. Metaanalysis showed a mean reduction of 0.24mm in the periodontal pockets (PD) at 3 months [MD, -0.25 with 95% CI -0.38 to -0.12]. Two trials revealed no significant difference PD≤3mm at 3 months, [MD, -1, 95% CI -22.54 to 20.53 (p=0.19)]. A decrease in periodontal pockets(PD≥4mm) and a reduction of 3.38mm in favour of SRP+antibiotics after 3 months [MD, -3.38, 95% CI -6.51 to -0.25 (p=0.93, I2=0%)] was observed for probing depth(PD). No significant difference in clinical attachment level (CAL) at 3 months [MD, -0.13, 95% CI -0.34 to 0.07; Chi2=0.98, df=3, p=0.81, I2=0%]. The overall quality of evidence was low largely because of attrition bias (24%; 32%) connoting high risk of bias and wide confidence intervals which suggests imprecision of results. Authors' conclusions: There is limited but low-level of evidence suggesting that systemic antibiotic therapy combined with mechanical debridement improves the systemic biomarker levels during the treatment of chronic periodontitis.