Childhood TB: can the End TB Strategy deliver?

The accelerated reductions in global TB incidence required to achieve the End TB Strategy goal will result in reductions in the burden of childhood TB. Contact screening and preventive therapy have emerged as important components of TB burden reduction, and family-centered approaches could be an effective route in delivering these activities. Lack of accurate diagnostics for children remains a critical barrier and a need remains for better collaborative and supportive links between the child health and TB control sectors. Irrespective of whether the ambitious targets can be achieved, the unprecedented opportunities provided by the End TB Strategy must be embraced.

An evaluation of chest X-ray in the context of community-based screening of child tuberculosis contacts

BACKGROUND

There are no published data on the critical review of chest X-ray (CXR) findings of children in the context of community-based contact screening.

OBJECTIVES

To describe the quality, findings and inter-observer agreement of CXRs in child TB contacts in Indonesia.

METHODS

We performed antero-posterior (AP) and lateral CXR in children who had had close contact with a pulmonary TB case. The CXRs were interpreted independently by four reviewers.

RESULTS

A total of 530 CXRs of 265 children were reviewed. Most (63%) of the children were asymptomatic at the time of CXR. Only 60% of the CXRs were reported as moderate to good quality by all reviewers, and inter-observer agreement on quality was slight to moderate (weighted κ = 0.16-0.35) for AP view. The majority of the CXRs were reported as normal (range 65-77%), with fair to moderate inter-observer agreement (κ = 0.25-0.46). Hilar lymphadenopathy (6-16%) was the most common CXR abnormality reported with poor inter-observer agreement (κ = -0.03 to 0.25).

CONCLUSION

The CXRs of child TB contacts investigated in the community were characterised by low quality, low agreement and low yield. Our findings support guidelines that CXR is not routinely indicated in asymptomatic child TB contacts in this setting.

Counting children with tuberculosis: why numbers matter

In the last 5 years, childhood tuberculosis (TB) has received increasing attention from international organisations, national TB programmes and academics. For the first time, a number of different groups are developing techniques to estimate the burden of childhood TB. We review the challenges in diagnosing TB in children and the reasons why cases in children can go unreported. We discuss the importance of an accurate understanding of burden for identifying problems in programme delivery, targeting interventions, monitoring trends, setting targets, allocating resources appropriately and providing strong advocacy. We briefly review the estimates produced by new analytical methods, and outline the reasons for recent improvements in our understanding and potential future directions. We conclude that while innovation, collaboration and better data have improved our understanding of the childhood TB burden, it remains substantially incomplete.

The epidemiology of tuberculosis in children in Australia, 2003-2012

OBJECTIVE

To describe the burden of and trends in paediatric tuberculosis (TB) in Australia between 2003 and 2012.

DESIGN

A retrospective analysis of TB data from the National Notifiable Diseases Surveillance System (NNDSS) on TB in children (under 15 years of age) during the 10-year period, 2003-2012.

RESULTS

TB notifications in Australia during the study period included 538 children (range, 37-66 cases per year), representing 4.6% of the total TB case load during the period (range, 3.8%-5.8% each year). Place of birth was recorded for 524 patients (97.4%); of these, 230 (43.9%) were born in Australia, 294 (56.1%) overseas. The average annual notification rate was 1.31 (95% CI, 1.20-1.43) cases per 100 000 child population. The rate was higher for overseas-born than for Australian-born children (9.57 [95% CI, 8.51-10.73] v 0.61 [95% CI, 0.53-0.69] cases per 100 000 children. The overall rate was highest among those aged 0-4 years. The annual notification rate was three times higher for Indigenous children than for non-Indigenous Australian-born children. Of 427 patients (79.4% of total) for whom the method of case detection was recorded, 37.0% were detected by contact screening, 8.7% by post-arrival immigration screening, and 54.3% by passive case detection. Pulmonary TB was the most common diagnostic classification (64.7% of patients). The most common risk factors were close contact with a TB case and recent residence in a country with a high incidence of TB. Treatment outcomes were satisfactory; 89.4% of children had completed treatment or were cured.

CONCLUSIONS

The burden of paediatric TB in Australia is low but has not changed over the past decade. The highest rates are among children born overseas, emphasising the important role of immigration screening as Australia aspires to eliminate TB.

Childhood tuberculosis: A roadmap towards zero deaths

'Every day, more than 200 children under the age of 15 die needlessly from tuberculosis (TB) - a disease that is preventable and curable. The World Health Organization estimates that as many as 1 in 10 TB cases globally (6-10% of all TB cases) are among this age group, but the number could be even higher because many children are simply undiagnosed.' Childhood TB is emerging from the shadows. This quote comes from the recently launched international roadmap towards zero TB deaths in children. We provide a brief update of new developments and remaining challenges related to childhood TB, with particular emphasis on the new roadmap.

Regional initiatives to address the challenges of tuberculosis in children: perspectives from the Asia-Pacific region

Increasing attention is being given to the challenges of management and prevention of tuberculosis in children and adolescents. There have been a number of recent important milestones achieved at the global level to address this previously neglected disease. There is now a need to increase activities and build partnerships at the regional and national levels in order to address the wide policy-practice gaps for implementation, and to take the key steps outlined in the Roadmap for Child Tuberculosis published in 2013. In this article, we provide the rationale and suggest strategies illustrated with examples to improve diagnosis, management, outcomes and prevention for children with tuberculosis in the Asia-Pacific region, with an emphasis on the need for greatly improved recording and reporting. Effective collaboration with community engagement between the child health sector, the National Tuberculosis control Programmes, community-based services and the communities themselves are essential.

Mycobacteria-Specific Cytokine Responses Detect Tuberculosis Infection and Distinguish Latent from Active Tuberculosis

RATIONALE

Current immunodiagnostic tests for tuberculosis (TB), including the tuberculin skin test and IFN-γ release assay (IGRA), have significant limitations, which include their inability to distinguish between latent TB infection (LTBI) and active TB, a distinction critical for clinical management.

OBJECTIVES

To identify mycobacteria-specific cytokine biomarkers that characterize TB infection, determine their diagnostic performance characteristics, and establish whether these biomarkers can distinguish between LTBI and active TB.

METHODS

A total of 149 children investigated for TB infection were recruited; all participants underwent a tuberculin skin test and QuantiFERON-TB Gold assay. In parallel, whole-blood assays using early secretory antigenic target-6, culture filtrate protein-10, and PPD as stimulatory antigens were undertaken, and cytokine responses were determined by xMAP multiplex assays.

MEASUREMENTS AND MAIN RESULTS

IFN-γ, interferon-inducible protein-10 (IP-10), tumor necrosis factor (TNF)-α, IL-1ra, IL-2, IL-13, and MIP-1β (macrophage inflammatory protein-1β) responses were significantly higher in LTBI and active TB cases than in TB-uninfected individuals, irrespective of the stimulant. Receiver operating characteristic analyses showed that IP-10, TNF-α, and IL-2 responses achieved high sensitivity and specificity for the distinction between TB-uninfected and TB-infected individuals. TNF-α, IL-1ra, and IL-10 responses had the greatest ability to distinguish between LTBI and active TB cases; the combinations of TNF-α/IL-1ra and TNF-α/IL-10 achieved correct classification of 95.5% and 100% of cases, respectively.

CONCLUSIONS

We identified several mycobacteria-specific cytokine biomarkers with the potential to be exploited for immunodiagnosis. Incorporation of these biomarkers into future immunodiagnostic assays for TB could result in substantial gains in sensitivity and allow the distinction between LTBI and active TB based on a blood test alone.

Clinical Case Definitions for Classification of Intrathoracic Tuberculosis in Children: An Update

Consensus case definitions for childhood tuberculosis have been proposed by an international expert panel, aiming to standardize the reporting of cases in research focusing on the diagnosis of intrathoracic tuberculosis in children. These definitions are intended for tuberculosis diagnostic evaluation studies of symptomatic children with clinical suspicion of intrathoracic tuberculosis, and were not intended to predefine inclusion criteria into such studies. Feedback from researchers suggested that further clarification was required and that these case definitions could be further improved. Particular concerns were the perceived complexity and overlap of some case definitions, as well as the potential exclusion of children with acute onset of symptoms or less severe disease. The updated case definitions proposed here incorporate a number of key changes that aim to reduce complexity and improve research performance, while maintaining the original focus on symptomatic children suspected of having intrathoracic tuberculosis. The changes proposed should enhance harmonized classification for intrathoracic tuberculosis disease in children across studies, resulting in greater comparability and the much-needed ability to pool study results.

The trend of tuberculosis cases over 60 years in Fiji's largest treatment centre: 1950-2010

SETTING

P J Twomey Hospital, National Tuberculosis Programme, Fiji.

OBJECTIVES

To review the trend in numbers of tuberculosis (TB) cases registered each year from 1950 to 2010 at P J Twomey Hospital, Fiji's largest TB treatment centre and central TB unit, and to consider trends in the context of key TB control events in Fiji.

DESIGN

Descriptive study of data from medical records and TB registers, including age, sex, ethnicity, TB diagnosis and smear result.

RESULTS

Between 1950 and 2010, 14 616 cases were registered at P J Twomey Hospital. Of these, 58% were male, 70% were indigenous Fijians (i-taukei) and 64% were aged 15-49 years. The caseload dropped sharply in the 1960s, and has fallen steadily since 1990. Smear results were available for the majority of cases (91%). Between 1950 and 1985, smear-positive cases accounted for 19% of cases overall; this increased to 41% after 1985 following laboratory training. The numbers of sputum smear-positive cases recorded each year has been increasing in the last decade.

CONCLUSION

There have been marked changes in TB caseload over the last 60 years at Fiji's largest TB treatment centre. The recent increase in smear-positive cases while total TB cases have been falling needs further evaluation.

A high burden of late-onset sepsis among newborns admitted to the largest neonatal unit in central Vietnam

OBJECTIVE

The objective of this study is to determine the prevalence, causes and outcome of sepsis in hospitalized neonates in the largest neonatal unit in central Vietnam.

STUDY DESIGN

A 1-year prospective cohort study of newborns admitted to the neonatal unit in Da Nang. A sepsis work-up including blood culture was undertaken before commencing antibiotics for neonates with suspected sepsis.

RESULT

Of 2555 neonatal admissions, 616 neonates had 729 episodes of suspected invasive sepsis. A pathogen was isolated from blood in 115 (16%) episodes in 106 neonates. The prevalence of early-onset sepsis (EOS) was 8 (95% confidence interval (CI): 4 to 11) per 1000 admissions, and of late-onset sepsis (LOS) was 34 (95% CI: 27 to 41) per 1000 admissions. Of 86 neonates with LOS, 69 (80%) also fulfilled the criteria for nosocomial sepsis. The commonest bacterial causes of EOS were coagulase-negative Staphylococcus (CoNS) and Staphylococcus aureus, and of LOS were Acinetobacter, CoNS and Klebsiella pneumoniae. Fungal sepsis occurred in 35 neonates of which most were nosocomial sepsis. In vitro resistance to multiple antibiotics was common among Gram-negative bacteria. Antibiotics were prescribed and given to 68% of all admissions, and 14% of all admissions received four or more different antibiotics. The case fatality rate for confirmed sepsis was 46%.

CONCLUSION

Late-onset, nosocomial sepsis was common and associated with a high mortality in hospitalized newborns in the largest neonatal unit in central Vietnam. These findings highlighted the need for improved infection control measures and antibiotic stewardship, which have since been implemented.

Changing from single-drug to fixed-dose combinations: experience from Fiji

BACKGROUND

Fixed-dose combinations (FDCs) of first-line anti-tuberculosis drugs were introduced in Fiji in 2011, and there have been concerns about treatment response.

OBJECTIVE

To evaluate the treatment response to FDCs among tuberculosis (TB) patients.

METHODS

A retrospective cohort study was undertaken of treatment outcomes of new TB cases registered from January 2010 to April 2013 and weighing ⩾30 kg. Sputum smear conversion of new sputum smear-positive cases and end-of-treatment outcomes of all cases were evaluated for those receiving FDCs and compared to outcomes with previous use of single-drug preparations.

RESULTS

Among new TB patients, 240 received single-drug preparations and 259 received FDCs for the full duration of treatment. The groups were similar in terms of demographic and clinical characteristics. Treatment outcomes were available for 95% of cases. Unknown outcomes were more common in those receiving FDCs. When known, end-of-treatment outcome was the same in the two treatment groups and did not differ between TB types. Sputum smear conversion after the 2-month intensive phase of treatment was similar in the two treatment groups: 95% and 97%, respectively.

CONCLUSION

The introduction of FDCs in Fiji for the treatment of TB cases has not been associated with changes in treatment response.

Clinical characteristics and treatment outcomes of tuberculosis cases hospitalised in the intensive phase in Fiji

SETTINGS

Tuberculosis (TB) is an ongoing public health challenge in Fiji. Clinical case detection and management are critical for effective TB control. Most TB cases in Fiji are hospitalised for the intensive phase of treatment.

OBJECTIVES

To describe the demographic and clinical characteristics, comorbidities and final treatment outcomes of TB patients hospitalised for the intensive phase of treatment in Fiji.

DESIGN

A retrospective, descriptive study of all TB cases hospitalised during the intensive phase over a 3-year period (2010-2012).

RESULTS

A total of 395 TB hospitalised cases were included, of whom 61% were sputum smear-positive. The largest proportions of cases were among young adults (15-34 years) and the unemployed, respectively 43% and 71%. Diabetes (13%) and smoking (22%) were common comorbidities. Final anti-tuberculosis treatment outcomes were available for 96% of cases; 81% were cured or completed treatment. Default was more common in those with current employment. Death was the final treatment outcome in 4%, and was more common (11%) in the oldest group aged 355 years (OR 5.7, 95%CI 1.9-17).

CONCLUSION

This study provides original and comprehensive descriptive data on TB cases in Fiji and identifies characteristics associated with poor treatment outcomes.

Adoption of revised dosage recommendations for childhood tuberculosis in countries with different childhood tuberculosis burdens

BACKGROUND AND OBJECTIVE

In 2010, the World Health Organization (WHO) published revised dosage recommendations for the treatment of tuberculosis (TB) in children. The aim of the survey was to assess whether countries adopt these new dosage recommendations, as well as to identify challenges in the management and treatment of childhood TB. In addition, countries were asked to provide 2010 surveillance data on childhood TB.

DESIGN

A survey questionnaire was developed and broadly disseminated to National Tuberculosis Programmes or people with close links to them.

RESULTS

Among the 34 countries that responded to the survey, the proportion of total national TB caseload reported in children in 2010 ranged from 0.67% to 23.6%. The data on new cases reported to this survey varied from data provided to the WHO global TB database. Most countries had childhood TB guidelines in place, and half had adopted the new dosage recommendations. Countries reported a number of challenges related to the implementation of the new recommendations and general management of childhood TB.

CONCLUSIONS

Despite the adoption of the new dosage recommendations, their implementation is complicated by the lack of appropriate fixed-dose combinations. In addition, accurate and consistent estimates of the global burden of childhood TB remained a major challenge. Technical assistance and support to countries is needed to improve childhood TB activities.

Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open, randomised controlled trial

BACKGROUND

In developing countries, mortality in children with very severe pneumonia is high, even with the provision of appropriate antibiotics, standard oxygen therapy, and other supportive care. We assessed whether oxygen therapy delivered by bubble continuous positive airway pressure (CPAP) improved outcomes compared with standard low-flow and high-flow oxygen therapies.

METHODS

This open, randomised, controlled trial took place in Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh. We randomly assigned children younger than 5 years with severe pneumonia and hypoxaemia to receive oxygen therapy by either bubble CPAP (5 L/min starting at a CPAP level of 5 cm H2O), standard low-flow nasal cannula (2 L/min), or high-flow nasal cannula (2 L/kg per min up to the maximum of 12 L/min). Randomisation was done with use of the permuted block methods (block size of 15 patients) and Fisher and Yates tables of random permutations. The primary outcome was treatment failure (ie, clinical failure, intubation and mechanical ventilation, death, or termination of hospital stay against medical advice) after more than 1 h of treatment. Primary and safety analyses were by intention to treat. We did two interim analyses and stopped the trial after the second interim analysis on Aug 3, 2013, as directed by the data safety and monitoring board. This trial is registered at ClinicalTrials.gov, number NCT01396759.

FINDINGS

Between Aug 4, 2011, and July 17, 2013, 225 eligible children were recruited. We randomly allocated 79 (35%) children to receive oxygen therapy by bubble CPAP, 67 (30%) to low-flow oxygen therapy, and 79 (35%) to high-flow oxygen therapy. Treatment failed for 31 (14%) children, of whom five (6%) had received bubble CPAP, 16 (24%) had received low-flow oxygen therapy, and ten (13%) had received high-flow oxygen therapy. Significantly fewer children in the bubble CPAP group had treatment failure than in the low-flow oxygen therapy group (relative risk [RR] 0·27, 99·7% CI 0·07-0·99; p=0·0026). No difference in treatment failure was noted between patients in the bubble CPAP and those in the high-flow oxygen therapy group (RR 0·50, 99·7% 0·11-2·29; p=0·175). 23 (10%) children died. Three (4%) children died in the bubble CPAP group, ten (15%) children died in the low-flow oxygen therapy group, and ten (13%) children died in the high-flow oxygen therapy group. Children who received oxygen by bubble CPAP had significantly lower rates of death than the children who received oxygen by low-flow oxygen therapy (RR 0·25, 95% CI 0·07-0·89; p=0·022).

INTERPRETATION

Oxygen therapy delivered by bubble CPAP improved outcomes in Bangladeshi children with very severe pneumonia and hypoxaemia compared with standard low-flow oxygen therapy. Use of bubble CPAP oxygen therapy could have a large effect in hospitals in developing countries where the only respiratory support for severe childhood pneumonia and hypoxaemia is low-flow oxygen therapy. The trial was stopped early because of higher mortality in the low-flow oxygen group than in the bubble CPAP group, and we acknowledge that the early cessation of the trial reduces the certainty of the findings. Further research is needed to test the feasibility of scaling up bubble CPAP in district hospitals and to improve bubble CPAP delivery technology.

FUNDING

International Centre for Diarrhoeal Disease Research, Bangladesh, and Centre for International Child Health, University of Melbourne.

Potentially Modifiable Factors Associated with Death of Infants and Children with Severe Pneumonia Routinely Managed in District Hospitals in Malawi

OBJECTIVE

To investigate recognised co-morbidities and clinical management associated with inpatient pneumonia mortality in Malawian district hospitals.

METHODS

Prospective cohort study, of patient records, carried out in Malawi between 1st October 2000 and 30th June 2003. The study included all children aged 0-59 months admitted to the paediatric wards in sixteen district hospitals throughout Malawi with severe and very severe pneumonia. We compared individual factors between those that survived (n = 14 076) and those that died (n = 1 633).

RESULTS

From logistic regression analysis, predictors of death in hospital, adjusted for age, sex and severity grade included comorbid conditions of meningitis (OR =2.49, 95% CI 1.50-4.15), malnutrition (OR =2.37, 95% CI 1.94-2.88) and severe anaemia (OR =1.41, 95% CI 1.03-1.92). Requiring supplementary oxygen (OR =2.16, 95% CI 1.85-2.51) and intravenous fluids (OR =3.02, 95% CI 2.13-4.28) were associated with death while blood transfusion was no longer significant (OR =1.10, 95% CI 0.77-1.57) when the model included severe anaemia.

CONCLUSIONS

This study identified a number of challenges to improve outcome for Malawian infants and children hospitalised with pneumonia. These included improved assessment of co-morbidities and more rigorous application of standard case management.

Cumulative, additive benefits of memantine-donepezil combination over component monotherapies in moderate to severe Alzheimer's dementia: a pooled area under the curve analysis

INTRODUCTION

Treatment in moderate or severe Alzheimer's disease (AD) often involves adding memantine to a cholinesterase-inhibitor (ChEI: donepezil, galantamine, rivastigmine). Evidence from six-month randomized trials and long-term observational studies supports superiority of memantine-ChEI combination to ChEI monotherapy. We utilized area-under-the-curve (AUC) analysis to assess six-month cumulative treatment efficacy of memantine-donepezil combination versus component monotherapies on individual clinical domains and on a composite index.

METHODS

Data were pooled from 1,408 individuals with moderate to severe AD from four six-month randomized trials of memantine monotherapy (n = 570) or add-on therapy (donepezil-only subset: n = 847). AUC changes from baseline on measures of cognition (SIB), function (ADCS-ADL19), behavior (NPI), global status (CIBIC-Plus), and a composite index (4D-CI: equally weighted composite of four domain measures) were calculated using the trapezoidal rule and evaluated via analysis of covariance (ANCOVA) (2-sided-α = 0.05). AUC results were contrasted with visit-by-visit changes from baseline ("snapshot analysis"), performed using a mixed-effects model with repeated measures (MMRM).

RESULTS

Over the entire six-month period, placebo-only treatment was associated with significant cumulative worsening on all outcomes. Memantine-donepezil combination showed significantly greater AUC improvements (point x week) on the SIB, NPI, and CIBIC-Plus than placebo-donepezil (SIB: 68.4 versus 32.0, P = 0.019; NPI: -74.3 versus -28.2, P = 0.003; CIBIC-Plus: -2.5 versus 1.4, P = 0.006) and memantine-only monotherapies (SIB: 68.4 versus 12.0, P <0.001; NPI: -74.3 versus -7.4, P <0.001; CIBIC-Plus: -2.5 versus 2.7, P <0.001), whereas these comparisons were not significant for the ADCS-ADL19 (memantine-donepezil (1.4) versus placebo-donepezil (-0.9), P = 0.407; versus memantine-only (-12.2), P = 0.310). Composite index analysis demonstrated significant cumulative advantages of memantine-donepezil combination (630.0) over placebo-donepezil (344.7, P <0.001) and memantine-only (152.1, P <0.001) treatments. Combining memantine and donepezil had an additive effect. Compared with AUC analysis, baseline-to-endpoint change-score analysis underestimated effects of combination therapy, monotherapies, or both.

CONCLUSIONS

This large pooled area-under-the-curve analysis of randomized-trial data in moderate to severe AD provides ecologically valid support that adding memantine to stable donepezil results in overall clinical benefits that are additive compared with individual monotherapies, continue to accumulate through six-month treatment, and are at least 50% greater than those of monotherapies.

Morbidity and mortality in hospitalised neonates in central Vietnam

AIM

This study explored neonatal morbidity and mortality in hospitalised patients in central Vietnam and risk factors associated with mortality.

METHODS

We conducted a prospective cohort study of all newborn infants (<28 days) hospitalised in a neonatal unit over a 1-year period and followed until discharge. The main outcome measures were case fatality rate and the rate of different clinical diagnoses.

RESULTS

There were 2555 admissions during the study period. The leading primary causes of admissions were infections (41%), haematological problems such as jaundice (23%) and prematurity and its complications (18%). The overall case fatality rate was 8.6%, and it was 59% among very low-birthweight (<1500 g) neonates. Mortality was inversely associated with birthweight and gestational age. Of the 220 deaths, 57% occurred within the first 7 days of life. Although the causes of death were often multifactorial, the leading primary causes were infections (32%), prematurity and its complications (25%), birth defects (24%) and birth asphyxia (6%). Risk factors associated with death were being outborn, early gestational age, small for gestational age, confirmed sepsis and birth defects.

CONCLUSION

Mortality rates were high among hospitalised neonates in central Vietnam, and this paper suggests interventions that might improve outcomes.

Tuberculosis as a cause or comorbidity of childhood pneumonia in tuberculosis-endemic areas: a systematic review

Pneumonia is a major cause of morbidity and mortality in infants and children worldwide, with most cases occurring in tuberculosis-endemic settings. Studies have emphasised the potential importance of Mycobacterium tuberculosis in acute severe pneumonia in children as a primary cause or underlying comorbidity, further emphasised by the changing aetiological range with rollout of bacterial conjugate vaccines in high mortality settings. We systematically reviewed clinical and autopsy studies done in tuberculosis-endemic settings that enrolled at least 100 children aged younger than 5 years with severe pneumonia, and that prospectively included a diagnostic approach to tuberculosis in all study participants. We noted substantial heterogeneity between studies in terms of study population and diagnostic methods. Of the 3644 patients who had culture of respiratory specimens for M tuberculosis undertaken, 275 (7·5%) were culture positive, and an acute presentation was common. Inpatient case-fatality rate for pneumonia associated with tuberculosis ranged from 4% to 21% in the four clinical studies that reported pathogen-related outcomes. Prospective studies are needed in high tuberculosis-burden settings to address whether tuberculosis is a cause or comorbidity of childhood acute severe pneumonia.

Establishing a children's orthopaedic hospital for Malawi: A review after 10 years

BACKGROUND

BEIT CURE International Hospital (BCIH) opened in 2002 providing orthopaedic surgical services to children in Malawi. This study reviews the hospital's progress 10 years after establishment of operational services. In addition we assess the impact of the hospital's Malawi national clubfoot programme (MNCP) and influence on orthopaedic training.

METHODS

All operative paediatric procedures performed by BCIH services in the 10th operative year were included. Data on clubfoot clinic locations and number of patients treated were obtained from the MNCP. BCIH records were reviewed to identify the number of healthcare professionals who have received training at the BCIH.

RESULTS

609 new patients were operated on in the 10th year of hospital service. Patients were treated from all regions; however 60% came from Southern regions compared with the 48% in the 5th year. Clubfoot, burn contracture and angular lower limb deformities were the three most common pathologies treated surgically. In total BCIH managed 9,842 patients surgically over a 10-year period. BCIH helped to establish and co-ordinate the MNCP since 2007. At present the program has a total of 29 clinics, which have treated 5748 patients. Furthermore, BCIH has overseen the full or partial training of 5 orthopaedic surgeons and 82 orthopaedic clinical officers in Malawi.

CONCLUSION

The BCIH has improved the care of paediatric patients in a country that prior to its establishment had no dedicated paediatric orthopaedic service, treating almost 10,000 patients surgically and 6,000 patients in the MNCP. This service has remained consistent over a 10-year period despite times of global austerity. Whilst the type of training placement offered at BCIH has changed in the last 10 years, the priority placed on training has remained paramount. The strategic impact of long-term training commitments are now being realised, in particular by the addition of Orthopaedic surgeons serving the nation.

A descriptive study of urethral discharge among men in Fiji

INTRODUCTION

Urethral discharge is a common presentation of sexually transmitted infection (STI) in men and known pathogens include Neisseria gonorrhoeae and Chlamydia trachomatis. There are no published data of the burden of urethral discharge among men in Fiji.

OBJECTIVE

To evaluate urethral discharge among men to determine the incidence, the frequency of recurrence and reported at-risk behaviour.

METHODS

We conducted a retrospective, descriptive study of clinical records of all men presenting with urethral discharge to two major reproductive health clinics. Data collected included self-reported at-risk behaviours, results of abnormal syphilis serology and antibiotics prescribed. The frequency of recurrence in the following 1-2 years of initial presentation was determined along with microbiological findings from urethral swab in this group.

RESULTS

A total of 748 males presented with urethral discharge to the clinic in one year. This represents an incidence rate of at least 295 per 100,000 adult males per year in the study population. Within the next 1-2 years of the initial presentation, 102 (14%) of these re-presented out of which 42 had urethral swab taken for etiological diagnosis. The commonest isolate was Neisseria gonorrhoeae. Results of syphilis tests were available for 560 (75%) of patients and 29 (5%) were positive. Recurrence was not associated with self-reported at-risk behaviours.

CONCLUSION

The incidence of urethral discharge among males in Fiji is very high and prevention strategies are urgently needed.