TY - JOUR
T1 - Validation of community health worker identification of maternal puerperal sepsis using a clinical diagnostic algorithm in Bangladesh and Pakistan
AU - LeFevre, Amnesty E.
AU - Mir, Fatima
AU - Mitra, Dipak K.
AU - Ariff, Shabina
AU - Mohan, Diwakar
AU - Ahmed, Imran
AU - Sultana, Shazia
AU - Winch, Peter J.
AU - Shakoor, Sadia
AU - Connor, Nicholas E.
AU - Islam, Mohammad Shahidul
AU - El-Arifeen, Shams
AU - Quaiyum, M. A.
AU - Baqui, Abdullah H.
AU - Gravett, Michael G.
AU - Santosham, Mathuram
AU - Bhutta, Zulfiqar A.
AU - Zaidi, Anita
AU - Saha, Samir K.
AU - Ahmed, Saifuddin D.
AU - Soofi, Sajid
AU - Bartlett, Linda A.
N1 - Funding Information:
Abdullah H Baqui, USA; Linda A Bartlett, USA/Canada; Nasma Begum, Bangladesh; Zulfiqar Bhutta, Pakistan / Canada; Nicolas E Connor, Bangladesh/United Kingdom; Farzeen. Hirani, Pakistan; Aneeta Hotwani, Pakistan; MS Islam, Bangladesh; Imran Khan, Pakistan; Amnesty E. LeFevre, South Africa/ USA; Arif Mahmud, Bangladesh; Fatima Mir, Pakistan; Dipak K. Mitra, Bangladesh; Syed Mamun Moin, Bangladesh; MA Quaiyum, Bangladesh; Shahida Qureshi, Pakistan; If-tekhar Rafiqullah, Bangladesh; Megan E Reller, USA; Arun Dhutta Roy, Bangladesh/USA; Samir K Saha, Bangladesh; Sa-dia Shakoor, Pakistan; Sajid Soofi, Pakistan; Shazia Sultana, Pakistan; Yaqub Wasan, Bangladesh; Peter J Winch, USA; Anita Zaidi, Pakistan/USA Acknowledgements: The PP sepsis project was nested within the larger ANISA project infrastructure. We are grateful to the ANISA PIs and study staff for their willingness and exhaustive support to all facets of this project. The PP Sepsis supplement to ANISA is a partnership between the Johns Hopkins Bloomberg School of Public Health of the Johns Hopkins University (JHU), USA and Bangladesh; The Child Health Research Foundation (CHRF); the International Center for Diarrheal Disease Research, Bangladesh (icddr,b); Shimantik in Dhaka, Bangladesh; and The Aga Khan University (AKU) in Karachi, Pakistan. We especially wish to extend our gratitude and appreciation to Dr France Donnay of the Bill and Melinda Gates Foundation, and the Chair of our Technical Advisory Group (TAG): Michael Gravett. We also thank the TAG members: Frank Witter, Denise Jamieson, Jeffrey Smith, Ana Pilar Betran, and Md Abdul Halim. Finally, and most importantly, this project was made possible by the community health workers, health care providers, support staff and women of Matiari, Karachi and Sylhet all of whom generously committed their time and effort to generate findings reported here. Funding: Bill and Melinda Gates Foundation. Grant number: OppGH5307. Authorship contributions: AEL wrote the first draft. AEL and Diwakar M conducted the analyses with inputs from SDA, IM, and FM. LAB was the overarching study Principal Investigator (PI) and also wrote parts of and edited the manuscript. DKM and AHB are the Bangladesh study site PIs; FM and AZ are the Karachi site PIs; and ZAB, SS, SA are the Matiari site PIs. SS is the overall ANISA PI. All authors met ICMJE criteria for inclusion and approved the final version. Competing interests: The authors completed the ICMJE Declaration of Interest Form (available upon request from the corresponding author), and declare no conflicts of interest.
Funding Information:
The PP sepsis project was nested within the larger ANISA project infrastructure. We are grateful to the ANISA PIs and study staff for their willingness and exhaustive support to all facets of this project. The PP Sepsis supplement to ANISA is a partnership between the Johns Hopkins Bloomberg School of Public Health of the Johns Hopkins University (JHU), USA and Bangladesh; The Child Health Research Foundation (CHRF); the International Center for Diarrheal Disease Research, Bangladesh (icddr, b); Shimantik in Dhaka, Bangladesh; and The Aga Khan University (AKU) in Karachi, Pakistan. We especially wish to extend our gratitude and appreciation to Dr France Donnay of the Bill and Melinda Gates Foundation, and the Chair of our Technical Advisory Group (TAG): Michael Gravett. We also thank the TAG members: Frank Witter, Denise Jamieson, Jeffrey Smith, Ana Pilar Betran, and Md Abdul Halim. Finally, and most importantly, this project was made possible by the community health workers, health care providers, support staff and women of Matiari, Karachi and Sylhet all of whom generously committed their time and effort to generate findings reported here.
Publisher Copyright:
© 2021 The Author(s) JoGH. All Rights Reserved.
PY - 2021
Y1 - 2021
N2 - Background Puerperal sepsis (PP sepsis) is a leading cause of maternal mortality globally. The majority of maternal sepsis cases and deaths occur at home and remain undiagnosed and under-reported. In this paper, we present findings from a nested case-control study in Bangladesh and Pakistan which sought to assess the validity of community health worker (CHW) identification of PP sepsis using a clinical diagnostic algorithm with physician assessment and classification used as the gold standard. Methods Up to 300 postpartum women were enrolled in each of the 3 sites 1) Sylhet, Bangladesh (n = 278), 2) Karachi, Pakistan (n = 278) and 3) Matiari, Pakistan (n = 300). Index cases were women with suspected PP Sepsis as diagnosed by CHWs clinical assessment of one or more of the following signs and symptoms: temperature (recorded fever >38.1°C, reported history of fever, lower abdominal or pelvic pain, and abnormal or foul-smelling discharge. Each case was matched with 3 control women who were diagnosed by CHWs to have no infection. Cases and controls were assessed by trained physicians using the same algorithm implemented by the CHWs. Using physician assessment as the gold standard, Kappa statistics for reliability and diagnostic validity (sensitivity and specificity) are presented with 95% CI. Sensitivity and specificity were adjusted for verification bias. Results The adjusted sensitivity and specificity of CHW identification of PP sepsis across all sites was 82% (Karachi: 78%, Matiari: 78%, Sylhet: 95%) and 90% (Karachi: 95%, Matiari: 85%, Sylhet: 90%) respectively. CHW-Physician agreement was highest for moderate and high fever (range across sites: K = 0.84-0.97) and lowest for lower abdominal pain (K = 0.30-0.34). The clinical signs and symptoms for other conditions were reported infrequently, however, the CHW-physician agreement was high for all symptoms except severe headache/ blurred vision (K = 0.13-0.38) and reported “lower abdominal pain without fever” (K = 0.39-0.57). Conclusion In all sites, CHWs with limited training were able to identify signs and symptoms and to classify cases of PP sepsis with high validity. Integrating postpartum infection screening into existing community-based platforms and post-natal visits is a promising strategy to monitor women for PP sepsis - improving delivery of cohesive maternal and child health care in low resource settings.
AB - Background Puerperal sepsis (PP sepsis) is a leading cause of maternal mortality globally. The majority of maternal sepsis cases and deaths occur at home and remain undiagnosed and under-reported. In this paper, we present findings from a nested case-control study in Bangladesh and Pakistan which sought to assess the validity of community health worker (CHW) identification of PP sepsis using a clinical diagnostic algorithm with physician assessment and classification used as the gold standard. Methods Up to 300 postpartum women were enrolled in each of the 3 sites 1) Sylhet, Bangladesh (n = 278), 2) Karachi, Pakistan (n = 278) and 3) Matiari, Pakistan (n = 300). Index cases were women with suspected PP Sepsis as diagnosed by CHWs clinical assessment of one or more of the following signs and symptoms: temperature (recorded fever >38.1°C, reported history of fever, lower abdominal or pelvic pain, and abnormal or foul-smelling discharge. Each case was matched with 3 control women who were diagnosed by CHWs to have no infection. Cases and controls were assessed by trained physicians using the same algorithm implemented by the CHWs. Using physician assessment as the gold standard, Kappa statistics for reliability and diagnostic validity (sensitivity and specificity) are presented with 95% CI. Sensitivity and specificity were adjusted for verification bias. Results The adjusted sensitivity and specificity of CHW identification of PP sepsis across all sites was 82% (Karachi: 78%, Matiari: 78%, Sylhet: 95%) and 90% (Karachi: 95%, Matiari: 85%, Sylhet: 90%) respectively. CHW-Physician agreement was highest for moderate and high fever (range across sites: K = 0.84-0.97) and lowest for lower abdominal pain (K = 0.30-0.34). The clinical signs and symptoms for other conditions were reported infrequently, however, the CHW-physician agreement was high for all symptoms except severe headache/ blurred vision (K = 0.13-0.38) and reported “lower abdominal pain without fever” (K = 0.39-0.57). Conclusion In all sites, CHWs with limited training were able to identify signs and symptoms and to classify cases of PP sepsis with high validity. Integrating postpartum infection screening into existing community-based platforms and post-natal visits is a promising strategy to monitor women for PP sepsis - improving delivery of cohesive maternal and child health care in low resource settings.
UR - http://www.scopus.com/inward/record.url?scp=85122842919&partnerID=8YFLogxK
U2 - 10.7189/JOGH.11.04039
DO - 10.7189/JOGH.11.04039
M3 - Article
C2 - 34912547
AN - SCOPUS:85122842919
SN - 2047-2978
VL - 11
JO - Journal of Global Health
JF - Journal of Global Health
M1 - 04039
ER -