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Improving Access to Secondary Prevention of RHD
Mitigating Fear of Anaphylactic Penicillin Allergy in Zambia
Dr. John Musuku
University Teaching Hospital, Lusaka
PASCAR Annual Meeting, Mauritius
October 2015
2
RHD: Mitigating Fear of Penicillin Allergy | October 2015
“Beat RHD Zambia” program: Overview
Goal is to eliminate RHD in Zambia through a combination of:
• Research
• Health systems strengthening
• Public education and awareness
3 year project
PPP led by UTH and including MoH, MoE, University of Zambia, University of Cape Town, Novartis, and others
Health
System
Strengthening
Research
Public Education
and Awareness
RHD: Mitigating Fear of Penicillin Allergy | October 2015
Background
RHD: Mitigating Fear of Penicillin Allergy | October 2015
Injectable penicillin is recommended for secondary prevention of RHD
In Zambia we discovered that fear of penicillin allergy is a concern causing health workers’ failed compliance with established guidelines
This came to light initially through “confessions” by numerous staff
To address this concern, we designed and implemented a citywide penicillin allergy workshop in Lusaka, Zambia
This is, to our knowledge, the first report of such a workshop
Objective
RHD: Mitigating Fear of Penicillin Allergy | October 2015
We sought to characterize:
• Changes in knowledge
• Trainees’ perceptions of the utility of the course.
2-day penicillin allergy workshop conducted at University Teaching Hospital in July 2013
Dr. Aidan Long, visiting professor, Chief of Allergy at Massachusetts General Hospital, Harvard Medical School
Curriculum drawn from evidence-based guidelines from the World Allergy Organization
Interactive didactic sessions, peer-to-peer learning, and a skills session focused on anaphylaxis management
Pre- and post-testing with 10-item multiple-choice questionnaire and standardized 5-point scale for skills sessions
• Mean test scores were compared using paired Wilcoxon signed rank sum testing (SOFA software, v1.3.4)
Methods
RHD: Mitigating Fear of Penicillin Allergy | October 2015
Pre- and post-questionnaire and skills test
RHD: Mitigating Fear of Penicillin Allergy | October 2015
Penicillin Allergy Training: Knowledge Test Code#: ____________
Circle one: PRE or POST
1. An “adverse drug reaction” is the same condition as a “drug allergy.”
a. True
b. False
2. How many people will have an allergy to a penicillin injection? (choose one answer)
a. Many (>10%)
b. Some (5-10%)
c. Few (<5%)
3. Allergic reactions to penicillin are more common when: (choose one answer)
a. The penicillin injection is in the arm
b. The penicillin injection is in the buttock
c. The penicillin injection is given very rapidly
d. The penicillin injection is given very slowly
e. None of the above
4. Name 4 signs or symptoms of an allergic reaction to penicillin:
5. Name 2 signs or symptoms of anaphylaxis:
6. What is the most important intervention for someone who develops anaphylaxis:
7. Most reactions due to penicillin allergy will: (choose one answer)
a. Involve the skin only
b. Cause difficulty breathing
c. Lead to scarring
d. Be life-threatening
8. Who can give emergency medicine to a patient that has anaphylaxis? (choose one answer)
a. Doctors only
b. Doctors and nurses
c. Doctors, nurses, and patient families
9. A child had an allergic reaction to penicillin that was successfully treated. Which statement is true?
a. The child can receive future doses of penicillin without any problem.
b. The child should not receive future doses of penicillin.
c. Nobody in the child’s family should receive penicillin in the future.
d. It is fine for the child to receive penicillin in the future, as long as the dose is small.
10. Name four medicines that are used to treat penicillin allergic reactions:
This is the end of the test. Thank you very much!
Information about this test:
Thank you for taking this test. Your responses will help us understand how best to address learner needs in this
and future workshops. You will not be identified other than by the code# indicated at the top of the sheet. There
are 10 questions on this test.
Instructions:
1. Please circle if the evaluation is taking place before (PRE) or after (POST) the training.
2. Please answer each question to the best of your ability.
3. Please make note of the number at the top of this form and write the same number on the form used at
the conclusion of the workshop.
Anaphylaxis management: Role play skills session
Penicillin Allergy Training: Anaphylaxis Skill Check Code#:_____________
Circle one: PRE or POST
Evaluation and data form instructions:
1. Please circle if the evaluation is taking place before (PRE) or after (POST) the training.
2. For each step, learners have to do the actions listed below. The actions can be performed
simultaneously (in any order) as long as #3 immediately follows #2.
3. After the learner has completed the skills test, indicate in the “Scoring” box how many steps
(of 5) are ticked “Done.”
1. Call for help.
2. Properly prepare the epinephrine injection.
-Remove the safety cap on an auto-injector, or draw up a
syringe correctly if no auto-injector is available.
3. Administer the epinephrine injection at the correct site.
-In the mid-anterolateral aspect of the thigh.
4. Place the patient in the correct position.
-Place patient on the back and elevate the lower extremities.
5. Assess the patients’ vital signs.
-Measure heart rate, respiratory rate, and blood pressure
!
Done%%%%%%%%%Not%Done%
Scoring:
Number of steps ticked “done” = ______ of 5
Facilitator initials: ____________
!
Penicillin Allergy Training: Anaphylaxis Skill Check Code#:_____________
Circle one: PRE or POST
Evaluation and data form instructions:
1. Please circle if the evaluation is taking place before (PRE) or after (POST) the training.
2. For each step, learners have to do the actions listed below. The actions can be performed
simultaneously (in any order) as long as #3 immediately follows #2.
3. After the learner has completed the skills test, indicate in the “Scoring” box how many steps
(of 5) are ticked “Done.”
1. Call for help.
2. Properly prepare the epinephrine injection.
-Remove the safety cap on an auto-injector, or draw up a
syringe correctly if no auto-injector is available.
3. Administer the epinephrine injection at the correct site.
-In the mid-anterolateral aspect of the thigh.
4. Place the patient in the correct position.
-Place patient on the back and elevate the lower extremities.
5. Assess the patients’ vital signs.
-Measure heart rate, respiratory rate, and blood pressure
!
Done%%%%%%%%%Not%Done%
Scoring:
Number of steps ticked “done” = ______ of 5
Facilitator initials: ____________
!
Penicillin Allergy Training: Anaphylaxis Skill Check Code#:_____________
Circle one: PRE or POST
Evaluation and data form instructions:
1. Please circle if the evaluation is taking place before (PRE) or after (POST) the training.
2. For each step, learners have to do the actions listed below. The actions can be performed
simultaneously (in any order) as long as #3 immediately follows #2.
3. After the learner has completed the skills test, indicate in the “Scoring” box how many steps
(of 5) are ticked “Done.”
1. Call for help.
2. Properly prepare the epinephrine injection.
-Remove the safety cap on an auto-injector, or draw up a
syringe correctly if no auto-injector is available.
3. Administer the epinephrine injection at the correct site.
-In the mid-anterolateral aspect of the thigh.
4. Place the patient in the correct position.
-Place patient on the back and elevate the lower extremities.
5. Assess the patients’ vital signs.
-Measure heart rate, respiratory rate, and blood pressure
!
Done%%%%%%%%%Not%Done%
Scoring:
Number of steps ticked “done” = ______ of 5
Facilitator initials: ____________
!
World Allergy Organization guidelines, 2011 RHD: Mitigating Fear of Penicillin Allergy | October 2015
Results
RHD: Mitigating Fear of Penicillin Allergy | October 2015
29 health workers (mostly nurses and doctors) with >20 health centers represented
Fear of giving penicillin was corroborated in a focus group discussion; nearly all trainees heard anecdotes of penicillin-induced harm, but few knew details and only one had previous training in drug allergy recognition and management
Knowledge scores: improved from 7.8/10 (SD 1.6) to 9.8/10 (SD 0.4; p<0.001); Skill scores: improved from 2.5/5 (SD 1.4) to 4.8/5 (SD 0.4; p<0.001)
In anonymous post-course evaluations, all participants reported that their clinical practice would change as a result of the course
Conclusion
RHD: Mitigating Fear of Penicillin Allergy | October 2015
Fear of drug allergy may be an under-recognized barrier to secondary prevention of RHD
In Zambia, health workers demonstrated improved knowledge and skills after a penicillin allergy workshop
To safeguard essential medical care for patients with RHD globally, stakeholders in similar contexts should explore whether drug allergy fear hinders secondary prevention in their programs
Program update
7 clinics in Lusaka enrolled in an RHD primary and secondary prevention pilot program implemented by “BeatRHD Zambia”
Government stocks of injectable penicillin are being enhanced with donated medicine
>1,000 doses of injectable penicillin administered with only 1 case of mild allergy
*Note, one comment from clinic nurses: the 1.2 m IU formulation (donated stock) was preferred to the 2.4 m IU formulation (supplied by government)
RHD: Mitigating Fear of Penicillin Allergy | October 2015
RHD: Mitigating Fear of Penicillin Allergy | October 2015
Health workers’ fear of adverse effects from injectable penicillin was identified as a barrier to standard care
Working with Harvard’s Massachusetts General Hospital, we developed a program to help mitigate this fear
Components:
• Penicillin, allergy, and adverse effect trainings
• Educational video
• Production and distribution of drug allergy emergency kits
Allergy kits are stocked at health clinics that have been recruited into the health system strengthening program
Bundled kit containing key materials needed to initiate
management of a penicillin-induced allergic reaction
Clear, concise
instructions, taken from
WHO/WHF, for emergent
steps to be taken in event
of serious allergic reaction
Medicines clearly
displayed and
labeled to facilitate
quick and proper use
Medicines include injectable
epinephrine, oral antihistamine,
albuterol MDI, and oral
glucocorticoid
Penicillin allergy kit
Action taken! Allergy training video
RHD: Mitigating Fear of Penicillin Allergy | October 2015
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RHD: Mitigating Fear of Penicillin Allergy | October 2015
Thank you!
