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Building Neurological Capacity In Zambia

In Zambia, exponential growth in general neurology capacity is coinciding with significant gains in stroke care and stroke research. Dr Deanna Saylor, associate professor of neurology at John Hopkins Medicine, outlines their approach.
Angels team 28 October 2022

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Zambia is a country in South-Central Africa whose 18 million population face a high burden of neurological disease. Prior to 2018, all neurological care was provided by four expatriate neurologists who were based in Zambia, some for only part of the year. With such limited access to neurological services, most patients with neurological disorders were cared for by non-specialists, and there was no specialized neurology inpatient service anywhere in the country.   

However, in October 2018, the first neurology post-graduate training program and first neurology inpatient service in Zambia were launched under the leadership of Dr. Deanna Saylor (Johns Hopkins) at the University Teaching Hospital (UTH) in the capital city of Lusaka. It was enjoyed the support of the University of Zambia School of Medicine, the Zambia Ministry of Health, and the Specialty Training Programme of the Zambia College of Medicine and Surgery. 

In the four years since, this program has trained four adult neurologists and two pediatric neurologists. Two more adult neurologists  will complete training this October, and one adult neurologist has returned from training at the University of Cape Town and joined the UTH consultant team. 

Five more doctors are currently undergoing training in neurology, and additional future neurologists are completing their post-graduate training in medicine, a prerequisite for joining the program.

In short, Zambia is projected to have at least 15 locally trained neurologists by 2023, with the number expected to grow annually.

Our team has been able to leverage this exponential growth in general neurology capacity to simultaneously make significant gains in stroke care, stroke systems development, and stroke research. We approached this problem in several ways.

Optimizing stroke diagnosis and management

First, we focused on optimizing stroke diagnosis and management. Focusing on providing rigorous clinical training for our neurology post-graduates helped us to hone the diagnosis of stroke, as a result of which stroke mimics were more readily identified, and stroke etiologies more thoroughly considered. 

This in turn led to better management of stroke risk factors and the initiation of patient-specific secondary stroke prevention regimens.

Our neurology team also focused on working collaboratively in an inter-disciplinary manner to discuss and provide better stroke care. This includes elevating the head of patients’ beds to prevent aspiration pneumonia, minimizing the use of urinary catheters, and ensuring patients are turned frequently.  These efforts have led to significant gains in short-term stroke outcomes.  For example, a 2012 study of stroke at UTH found an inpatient mortality of 40%1. After the introduction of the neurology training program in 2018, this number declined to 24%2.

Finding evidence to guide our clinical practice

Secondly, we have focused on finding evidence to guide our clinical practice as it pertains to clinical questions that are common in our setting. For example, unlike in most high-income settings, most of our patients with stroke cannot access neuroimaging in a timely manner due to financial constraints or the unavailability of neuroimaging in a particular facility. This means that most of our patients undergo CT scans more than 24 hours after admission, and 10-15% do not access neuroimaging at all. This means that we are often making critical clinical decisions about management, including blood pressure targets and whether or not to initiate antiplatelet therapy, without knowing whether a patient has an ischemic or hemorrhagic stroke.

We were surprised but excited to find that a fairly substantial evidence base about this clinical scenario of “unknown stroke” actually existed, and we have used it to guide our clinical practice and to propose a framework for others in similar clinical settings.3

Data gathering and analysis

Finally, we have purposefully approached the development of our fledgling stroke services in a data-driven, systematic and scientific manner by gathering data from our routine clinical practice.  When analyzed, these data have allowed us to have a better understanding of the epidemiology we are encountering in our clinical services, including the proportion of ischemic and hemorrhagic strokes and the most common stroke risk factors amongst our patients.2,2,4 

These data have also helped us to better understand our patient outcomes and the drivers of those outcomes,5 which has in turn helped us focus on understanding and intervening on modifiable factors associated with poor outcomes such as aspiration pneumonia.6 They have also informed our ongoing efforts to better understand post-discharge mortality and how we can improve the transition from hospital to home for our patients. In this way, our research is performed as part of and integrated with our clinical care, and our research results directly inform improvements in our ongoing clinical care. 

While our team has already accomplished a great deal in a relatively short period of time, we have many more ambitious goals and projects that we are excited about and striving towards. Current efforts include:

  • research projects to better utilize bedside caregivers in the routine care of stroke patients to prevent in-hospital complications and improve outcomes
  • studies to understand and improve post-discharge mortality
  • development of an evidence-based stroke center that is feasible in our resource-limited environment. 

In the long term we hope that our data and advocacy efforts will lead to national stroke care guidelines and, eventually, access to thrombolysis and thrombectomy for our patients. 

Although much about the future is inherently uncertain, one thing we know for sure is that the past four years of neurology growth in Zambia have shown us that so much is possible with hard work, capacity building, a data-driven approach, and, most importantly, an excellent team comprised of patient-centered, academic-oriented, driven neurologists!

This article first appeared in the newsletter of the African Stroke Organizaion, November 2022

Atadzhanov M, Mukomena PN, Lakhi S, Ross OA, Meschia JF.  Stroke characteristics and outcomes of adult patients admitted to the University Teaching Hospital, Lusaka, Zambia.  Open General and Internal Medicine Journal. 2012;5:3-8.

Nutakki A, Chomba M, Chishimba L, Zimba S, Gottesman R, Bahouth M, *Saylor D. Risk Factors and Outcomes of Hospitalized Stroke Patients in Zambia.  J Neurol Sci.  2021;424:117404.

Prust M, Saylor D, Zimba S, Sarfo FS, Shrestha GS, Berkowitz A, Vora N.  Inpatient management of acute stroke of unknown type in resource-limited settings.  Stroke.  2022;53:e108-e177.

Zimba S, Nutakki A, Chishimba L, Chomba M, Bahouth MN, Gottesman RF, Saylor D.  Risk factors and outcomes of HIV-associated stroke in Zambia.  AIDS.  2021;35:2149-2155.

Nutakki A, Chomba M, Chishimba L, Mataa MM, Zimba S, Kvalsund M, Gottesman RF, Bahouth M, Saylor D.* Predictors of in-hospital and 90-day post-stroke mortality in Lusaka, Zambia. J Neurol Sci.  2022;437:120249.

Prust ML, Nutakki A, Habanyama G, Chishimba L, Chomba M, Mataa M, Yumbe K, Zimba S, Gottesman RF, Bahouth MN, *Saylor D.  Aspiration pneumonia in adults hospitalized with stroke at a large academic hospital in Zambia.  Neurol Clin Pract.  2021;11:e840-e847.  doi:10.1212/CPJ.0000000000001111

 

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