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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017
AFRICA
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multi-faceted initiative (called ‘BeatRHD Zambia’) is centred out
of the University Teaching Hospital (UTH) in Lusaka, Zambia,
and includes operational research (for example, to measure disease
prevalence), public awareness, and health system-strengthening
activities – in particular, efforts to increase appropriate BPG usage
for primary and secondary prevention of RHD in government
health facilities according to national guidelines.
To explore and address factors contributing to possible low
rates of BPG use among health workers in Zambia, we undertook
an assessment of health workers’ attitudes and practices relating
to BPG safety, appropriate use and effectiveness. The information
obtained was used to inform education and training, and
interventions for BPG access, which have been implemented in
health centres across Lusaka, Zambia, and are now being rolled
out in other provinces. This report describes the experience to
date of supporting the use of BPG for primary and secondary
prevention of RHD in Zambia.
Unmasking potential barriers to penicillin
administration
A two-day workshop was conducted at UTH in October 2014
in order to elicit participants’ knowledge, attitudes and practices
relating to RHD and BPG, and to provide education and
training on how to administer BPG. The workshop involved a
classroom-based didactic and interactive programme directed at
representatives from UTH and 20 government clinics in Lusaka.
There were 29 attendees, mostly nurses and a few doctors.
Focus group discussion
An initial focus group discussion (led by AL and JM) permitted
course leaders to gain insight into current patterns of penicillin
usage in cases of streptococcal pharyngitis and RHD. It allowed
for an informal exploration of factors that were perceived to limit
the use of BPG in these clinical circumstances. All 29 workshop
participants expressed awareness of the existence of RHD and
the majority reported having been involved in the care of such
patients. While most participants reported prior experience with
administration of oral penicillin VK and intramuscular penicillin
G, no participant was able to relate first-hand experience in the
administration of intramuscular BPG.
Precise identification of the reasons for the non-use of BPG was
challenging to ascertain but one theme appeared central: fear of
penicillin allergy as a potential barrier to administration of BPG
in Zambia. This concern had also been brought to light before the
workshop by personal interactions between Zambian nurses and
doctors and the head of Paediatrics at UTH (JM), which revealed
anxiety over a perceived high risk of penicillin allergy associated
with injectable penicillin (distinct from the oral form of penicillin).
During the focus group, a significant number of the
participants expressed grave fear of inducing an allergic
reaction, apparently based on anecdotal information they had
received secondhand about such events. No participant reported
directly having encountered an adverse drug reaction (including
allergic or anaphylactic reactions) with administration of any
formulation of penicillin. Only one participant had previous
training in drug-allergy recognition and management.
There appeared to be prevalent misconceptions that
anaphylactic reactions to BPG were common and were increased
in individuals who were fasting or otherwise weak. Most
programme participants were not aware that prior tolerance
of other forms of penicillin (such as oral penicillin VK or
intramuscular penicillin G) might have a bearing on the
subsequent risk of anaphylaxis to BPG. A small number of
participants inquired whether penicillin allergy testing would be
necessary before BPG administration.
Educational session
Informed by observations in the focus group, the educational
component of the workshop covered the following topics:
streptococcal pharyngitis and its relationship to RF and RHD;
the role of penicillin in primary and secondary prevention; review
of the various forms of penicillin, including BPG, penicillin VK
and penicillin G; use of penicillin in previously documented RHD
control programmes; the nature and likelihood of possible adverse
reactions to penicillin (including IgE-mediated type I allergic
reactions and other non-allergic adverse reactions); and how to
recognise and intervene in acute anaphylaxis. The educational
session also reviewed evidence that supported the lack of need to
conduct penicillin allergy testing (often simply called ‘skin testing’
locally) before BPG administration to a patient in whom there was
no prior history of adverse reaction to penicillin.
Following the didactic programme, a hands-on, role-playing
exercise was undertaken to teach recognition and management
of acute anaphylaxis in a simulated patient (Fig. 1), based on
algorithms developed by the World Allergy Organisation.
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Skills
imparted included placing the patient in the supine position
with the legs elevated, proper assessment of the patient’s
airway, correct administration of intramuscular epinephrine, and
determination of the potential need for additional medications
such as antihistamines and bronchodilators.
Educational activities were evaluated by pre- and post-
testing of knowledge and skills. All participants demonstrated
significantly improved anaphylaxis management skills, and in an
anonymous post-course evaluation, every participant reported
that their clinical practice would change as a result of the course.
Workshop learnings
Important lessons learned from the initial educational workshop
guided future programme activities. First, it was clear that
health workers in Zambia had had misconceptions about the
true frequency of severe penicillin allergic reactions. Second,
health workers received scant, if any, training in drug-allergy
recognition and management; therefore there was a need for
programmes to improve health workers’ confidence in managing
patients with drug allergy. Third, health workers were unclear
about the precise indications and dosing for administering BPG,
and were eager for opportunities to improve their diagnostic
and treatment skills. These were each felt to be remediable
contributory factors to the suboptimal use of BPG for primary
and secondary prevention of RHD in Zambia.
Design and deployment of subsequent
tailored interventions
Acore activityof theBeatRHDZambia initiative is towork tohelp
strengthen the Zambian health system in order that services for