Incorporating selected non-communicable diseases into facility-based surveillance systems from a resource-limited setting in Africa

Mavalane General Hospital (MGH) is a 239-bed hospital in the capital of Mozambique, serving nearly 800,000 people. It represents the prototype of secondary level hospitals in the country, which in Mozambique’s health system are the first referral hospitals capturing transfers from surrounding health centres, and providing beds for four specialties (Internal Medicine, Surgery/Traumatology, Pediatrics and Gynecology-Obstetrics). The National Public Health Institute (Instituto Nacional de Saúde, INS) holds the mandate to implement research that informs local health policy, and has adopted MGH for surveillance of endemic diseases (malaria, tuberculosis, HIVAIDS, parasitic diseases, diarrheal diseases) using tools approved by the Ministry of Health (MoH) to feed the Information System on Diseases of Compulsory Declaration. Daily consultations performed by doctors and clinical officers are registered in books from where nurses and administrative workers routinely extract data on CD targeted by national programs, to produce weekly reports that are centralized at the MoH. Because patient electronic management system is not available, identification cards are provided to patients to allow recovery of medical files for follow up.

Registration books used for consultations at entry points included patient’s name, age group (0–4 years; 5–14 years; > 15 years), diagnosis, treatment provided, type of visit (first or follow up) and observations (Additional file 1). For our study we proposed to replace age group by the exact patient’s age, to add and extra column with gender, and to use the observation’s column to register the immediate outcome (discharge, transfer or death).

All clinicians working in triage, out-patients clinics and emergency department, as well as administrative workers involved in surveillance attended a 5-days (30 h) course on NCD diagnosis, management and surveillance. Twenty doctors/clinical officers, 20 nurses and 12 administrative attended the course in groups of 16–18 health workers, to avoid stopping all clinical activities. INS researchers (AM, DC, SC) designed the training program and delivered with the support of leadership from the NCD National Program, senior researchers at INS and consultant specialists from relevant areas (Fig. 1). The three workshops were delivered over the 3 months prior to the study. Formal training and group discussions were used to discuss the topics and the hospital readiness to report on diseases targeted by the WHO Global Action Plan for the prevention and control of NCD 2013–2020 [10], prioritized in the Mozambique’s NCD Control Program [9] and adopted by the African Governments [11], but also to identify other conditions of interest to the group. Considering research data available, human resources available, diagnostic capacity and health worker’s perception of clinical relevance, we then selected the conditions that would be targeted for surveillance, namely: arterial hypertension, asthma, cancer, chronic obstructive pulmonary disease, diabetes, mental illnesses (depression, psychosis, epilepsy and alcohol abuse) and stroke [1‐3, 12‐19] (Table 1). One week before the starting of data collection a one-day workshop was delivered separately to clinicians – to review the updated registration books and the use of the international classification of diseases (ICD-10) [https://​en.​wikipedia.​org/​wiki/​ICD-10] – and to administrative workers and nurses – to train data extraction from registration books, building of daily reports, and use an Epi Info V.7 database for data entry. At this point a monitoring and evaluation plan was also agreed.

We prospectively collected data on all patients attending MGH between 1st February 2014 and 31st January 2015. INS researchers based at MGH were distributed by the different sectors of the hospital to i) provided support to those involved in data capture; ii) reviewed patient’s files and checked data sources to ensure data quality; iii) helped in defining the primary diagnosis when multiple conditions were listed. For logistical reasons we only entered in the database full data from patients with primary diagnosis of a selected NCD. To avoid duplication of entries the hospital identification cards of patients with selected NCD were labeled with a unique study identification number.

AM, DC and SC compiled data from all sectors weekly (all patients seen in hospital), and provided the health workers and hospital leadership with feedback on progression of the study and discussed areas for improvement on a monthly basis.

We performed descriptive analysis of patients with selected NCD. Age is presented as median and categorized in three groups: children (0–17), adults (18–64) and elderly (> 65). For gender, diagnosis and outcomes data is presented as percentages and proportions.

The national bioethics committee (IRB 000002657) approved the study.

The 6423 patients with NCD had median age 27 years and 58.4% were females. The diseases were distributed as follows: arterial hypertension (2397;37.31%), mental illness (1497;23.30%), asthma (1495;23.28%), diabetes (628;9.78%), stroke (299;4.66%), chronic obstructive pulmonary disease 61 (0.95%) and cancers 46 (0.72%).

Most patients were adults aged 18–64 (4665; 72.6%). The elderly (> 65 years) were proportionally more represented for chronic obstructive pulmonary disease (50.8%) and stroke (32.8%), while children and adolescents represented 43.4% of patients with asthma. Cancer was more frequent in adults 18–64 years (44 out of the 46 cases). The age distribution of patients for each selected condition is presented in Fig. 3.

Female predominance was marked for arterial hypertension (68,3% females vs 31.7% males) and depression (65.5% females vs 44.5 males), while there was male predominance for alcohol abuse (66.1% males vs 33.9% females). Table 2 shows gender distribution for each selected condition.

Emergency transfers were needed for 76 patients (1.2%) patients with selected NCD. The most common causes were hypertensive emergencies (31; 40.8%) and stroke (18; 23.7%). Of the 24 patients that died at entry points (0.3%) 16 were aged 18 to 64 years and 10 had hypertensive emergencies.