Causes and outcome of young infant admissions to a Kenyan district hospital

Group B streptococcal carriage, serotype distribution and antibiotic susceptibilities in pregnant women at the time of delivery in a refugee population on the Thai-Myanmar border

Background

Group B Streptococcus (GBS) is the leading cause of neonatal sepsis in the developed world. Little is known about its epidemiology in the developing world, where the majority of deaths from neonatal infections occur. Maternal carriage of GBS is a prerequisite for the development of early onset GBS neonatal sepsis but there is a paucity of carriage data published from the developing world, in particular South East Asia.

Methods

We undertook a cross sectional study over a 13 month period in a remote South East Asian setting on the Thai-Myanmar border. During labour, 549 mothers had a combined vaginal rectal swab taken for GBS culture. All swabs underwent both conventional culture as well as PCR for GBS detection. Cultured GBS isolates were serotyped by latex agglutination, those that were negative or had a weak positive reaction and those that were PCR positive but culture negative were additionally tested using multiplex PCR based on the detection of GBS capsular polysaccharide genes.

Results

The GBS carriage rate was 12.0% (95% CI: 9.4-15.0), with 8.6% positive by both culture and PCR and an additional 3.5% positive by PCR alone. Serotypes, Ia, Ib, II, III, IV, V, VI and VII were identified, with II the predominant serotype. All GBS isolates were susceptible to penicillin, ceftriaxone and vancomycin and 43/47 (91.5%) were susceptible to erythromycin and clindamycin.

Conclusions

GBS carriage is not uncommon in pregnant women living on the Thai-Myanmar border with a large range of serotypes represented.

Aetiology of community-acquired neonatal sepsis in low and middle income countries

BACKGROUND

99% of the approximate 1 million annual neonatal deaths from life-threatening invasive bacterial infections occur in developing countries, at least 50% of which are from home births or community settings. Data concerning aetiology of sepsis in these settings are necessary to inform targeted therapy and devise management guidelines. This review describes and analyses the bacterial aetiology of community-acquired neonatal sepsis in developing countries.

METHODS

A search of Medline, Embase, Global Health and Web of Knowledge, limited to post-1980, found 27 relevant studies. Data on aetiology were extracted, tabulated and analysed along with data on incidence, risk factors, case fatality rates and antimicrobial sensitivity.

RESULTS

The most prevalent pathogens overall were Staphylococcus aureus (14.9%), Escherichia coli (12.2%), and Klebsiella species (11.6%). However, variations were observed both between global regions and age-of-onset categories. Staphylococcus aureus and Streptococcus pneumoniae were most prevalent in Africa, while Klebsiella was highly prevalent in South-East Asia. A notably higher prevalence of Group B Streptococcus was present in neonates aged 7 days or less. The highest case fatality rates were recorded in South-East Asia. Klebsiella species showed highest antimicrobial resistance.

CONCLUSION

Data on community-acquired neonatal sepsis in developing countries are limited. Future research should focus on areas of high disease burden with relative paucity of data. Research into maternal and neonatal vaccination strategies and improved diagnostics is also needed. All of this could contribute to the formulation of community-based care packages, the implementation of which has significant potential to lower overall neonatal mortality and hence advance progress towards the attainment of Millennium Development Goal 4.

Quality of hospital care for sick newborns and severely malnourished children in Kenya: a two-year descriptive study in 8 hospitals

Background

Given the high mortality associated with neonatal illnesses and severe malnutrition and the development of packages of interventions that provide similar challenges for service delivery mechanisms we set out to explore how well such services are provided in Kenya.

Methods

As a sub-component of a larger study we evaluated care during surveys conducted in 8 rural district hospitals using convenience samples of case records. After baseline hospitals received either a full multifaceted intervention (intervention hospitals) or a partial intervention (control hospitals) aimed largely at improving inpatient paediatric care for malaria, pneumonia and diarrhea/dehydration. Additional data were collected to: i) examine the availability of routine information at baseline and their value for morbidity, mortality and quality of care reporting, and ii) compare the care received against national guidelines disseminated to all hospitals.

Results

Clinical documentation for neonatal and malnutrition admissions was often very poor at baseline with case records often entirely missing. Introducing a standard newborn admission record (NAR) form was associated with an increase in median assessment (IQR) score to 25/28 (22-27) from 2/28 (1-4) at baseline. Inadequate and incorrect prescribing of penicillin and gentamicin were common at baseline. For newborns considerable improvements in prescribing in the post baseline period were seen for penicillin but potentially serious errors persisted when prescribing gentamicin, particularly to low-birth weight newborns in the first week of life. Prescribing essential feeds appeared almost universally inadequate at baseline and showed limited improvement after guideline dissemination.

Conclusion

Routine records are inadequate to assess newborn care and thus for monitoring newborn survival interventions. Quality of documented inpatient care for neonates and severely malnourished children is poor with limited improvement after the dissemination of clinical practice guidelines. Further research evaluating approaches to improving care for these vulnerable groups is urgently needed. We also suggest pre-service training curricula should be better aligned to help improve newborn survival particularly.

A global need for affordable neonatal jaundice technologies

Globally, health care providers worldwide recognize that severe neonatal jaundice is a "silent" cause of significant neonatal morbidity and mortality. Untreated neonatal jaundice can lead to death in the neonatal period and to kernicterus, a major cause of neurologic disability (choreo-athetoid cerebral palsy, deafness, language difficulty) in children who survive this largely preventable neonatal tragedy. Appropriate technologies are urgently needed. These include tools to promote and enhance visual assessment of the degree of jaundice, such as simpler transcutaneous bilirubin measurements and readily available serum bilirubin measurements that could be incorporated into routine treatment and follow-up. Widespread screening for glucose-6-phoshate dehydrogenase deficiency is needed because this is often a major cause of neonatal jaundice and kernicterus worldwide. Recognition and treatment of Rh hemolytic disease, another known preventable cause of kernicterus, is critical. In addition, effective phototherapy is crucial if we are to make kernicterus a "never-event." Finally it is essential that we conduct appropriate population-based studies to accurately elucidate the magnitude of the problem. However, knowledge alone is not sufficient. If we are to implement these and other programs and technologies to relegate severe neonatal jaundice and its sequelae to the history books, screening and interventions must be low cost and technologically appropriate for low and middle income nations.

Systematic review: neonatal meningitis in the developing world

Meningitis is more common in the neonatal period than any other time in life and is an important cause of morbidity and mortality globally. Despite the majority of the burden occurring in the developing world, the majority of the existing literature originates from wealthy countries. Mortality from neonatal meningitis in developing countries is estimated to be 40-58%, against 10% in developed countries. Important differences exist in the spectrum of pathogens isolated from cerebrospinal fluid cultures in developed versus developing countries. Briefly, while studies in developed countries have generally found Group B streptococcus (GBS), Escherichia coli and Listeria monocytogenes as important organisms, we describe how in the developing world results have varied; particularly regarding GBS, other Gram negatives (excluding E. coli), Listeria and Gram-positive organisms. The choice of empiric antibiotics should take into consideration local epidemiology if known, early versus late disease, resistance patterns and availability within resource constraints. Gaps in knowledge, the role of adjuvant therapies and future directions for research are explored.

The role of weight for age and disease stage in poor psychomotor outcome of HIV-infected children in Kilifi, Kenya

AIM

We aimed to investigate the contribution of disease stage and weight for age to the variability in psychomotor outcome observed among children with human immunodeficiency virus (HIV) infection.

METHOD

This cross-sectional study involved 48 Kenyan children (20 females, 28 males) aged 6 to 35 months (mean 19.9mo SD 8.9) exposed prenatally to HIV. Two subgroups of HIV-exposed children were seen: those who were HIV-infected and those who were uninfected. The reference population was composed of 319 children (159 females, 160 males) aged 6-35 months, (mean age = 19 months, SD=8.43) randomly selected from the community. Disease stage varied from stage 1 to stage 3, reflecting progression from primary HIV infection to advanced HIV infection and acquired immune deficiency syndrome. A locally developed and validated measure, the Kilifi Developmental Inventory, was used to assess psychomotor development.

RESULT

Using age-corrected psychomotor scores, a significant main effect of HIV status was observed (F((2,38.01))=7.89, p<0.001). Children in the HIV-infected group had lower mean psychomotor scores than the HIV-exposed children and the reference group. In the HIV-infected group, disease stage was a negative predictor and weight for age a positive predictor of psychomotor outcome.

INTERPRETATION

Weight for age and disease stage provide viable, easily measurable benchmarks to specify when frequent developmental monitoring and psychomotor rehabilitation are required. Nutritional intervention and other measures aimed at slowing disease progression may delay the onset and severity of psychomotor impairment in the paediatric HIV population in Africa.

Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa

Maternal and child health are high priorities for international development. Through a Review of published work, we show substantial gaps in current knowledge on incidence (cases per live births), aetiology, and risk factors for both maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa. Although existing published data suggest that sepsis causes about 10% of all maternal deaths and 26% of neonatal deaths, these are likely to be considerable underestimates because of methodological limitations. Successful intervention strategies in resource-rich settings and early studies in sub-Saharan Africa suggest that the burden of maternal and early onset neonatal bacterial sepsis could be reduced through simple interventions, including antiseptic and antibiotic treatment. An effective way to expedite evidence to guide interventions and determine the incidence, aetiology, and risk factors for sepsis in sub-Saharan Africa would be through a multiarmed factorial intervention trial aimed at reducing both maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa.

The prevalence of hypoxaemia among ill children in developing countries: a systematic review

Hypoxaemia is a common complication of childhood infections, particularly acute lower respiratory tract infections. In pneumonia-a disease that disproportionately impacts developing countries, and accounts for more than two million deaths of children worldwide-hypoxaemia is a recognised risk factor for death, and correlates with disease severity. Hypoxaemia also occurs in severe sepsis, meningitis, common neonatal problems, and other conditions that impair ventilation and gas exchange or increase oxygen demands. Despite this, hypoxaemia has been overlooked in worldwide strategies for pneumonia control and reducing child mortality. Hypoxaemia is also often overlooked in developing countries, mainly due to the low accuracy of clinical predictors and the limited availability of pulse oximetry for more accurate detection and oxygen for treatment. In this Review of published and unpublished studies of acute lower respiratory tract infection, the median prevalence of hypoxaemia in WHO-defined pneumonia requiring hospitalisation (severe and very severe classifications) was 13%, but prevalence varied widely. This corresponds to at least 1.5 to 2.7 million annual cases of hypoxaemic pneumonia presenting to health-care facilities. Many more people do not access health care. With mounting evidence of the impact that improved oxygen systems have on mortality due to acute respiratory infection in limited-resource health-care facilities, there is a need for increased awareness of the burden of hypoxaemia in childhood illness.

Optimising the use of routine immunisation clinics for early childhood development in sub-Saharan Africa

There is now ample evidence that factors that account for high infant and child mortality in sub-Saharan Africa and other developing regions are also associated with lifelong developmental impairments in the survivors from early childhood. Of all routine immunisation programmes widely administered soon after birth, bacille Calmette-Guérin (BCG) and diphtheria-pertussis-tetanus (DPT) offer effective platforms to implement a package of interventions that extend beyond child survival to include the early detection and prompt management of developmental disabilities as recently demonstrated in some pilot programmes in sub-Saharan Africa. This paradigm shift is consistent with the Global Immunisation Vision and Strategy (GIVS) of UNICEF/WHO for integrated interventions. It also accords with the current early childhood development policies of all major UN organisations and the World Bank. Such integrated programmes should now be widely encouraged throughout the region by its developmental partners.

Adult and paediatric mortality patterns in a referral hospital in Liberia 1 year after the end of the war

The aim of this study was to describe and analyse hospital mortality patterns after the Liberian war. Data were collected retrospectively from January to July 2005 in a referral hospital in Monrovia, Liberia. The overall fatality rate was 17.2% (438/2543) of medical admissions. One-third of deaths occurred in the first 24h. The adult fatality rate was 23.3% (241/1034). Non-infectious diseases accounted for 56% of the adult deaths. The main causes of death were meningitis (16%), stroke (14%) and heart failure (10%). Associated fatality rates were 48%, 54% and 31% respectively. The paediatric fatality rate was 13.1% (197/1509). Infectious diseases caused 66% of paediatric deaths. In infants <1 month old, the fatality rate was 18% and main causes of death were neonatal sepsis (47%), respiratory distress (24%) and prematurity (18%). The main causes of death in infants > or =1 month old were respiratory infections (27%), malaria (23%) and severe malnutrition (16%). Associated fatality rates were 12%, 10% and 19%. Fatality rates were similar to those found in other sub-Saharan countries without a previous conflict. Early deaths could decrease through recognition and early referral of severe cases from health centres to the hospital and through assessment and priority treatment of these patients at arrival.

Infants with severe neonatal jaundice in Lagos, Nigeria: incidence, correlates and hearing screening outcomes

OBJECTIVES

To establish the incidence, correlates and hearing screening outcomes of infants with severe neonatal jaundice in Nigeria.

METHODS

Community-based study in which all infants attending Bacille Calmette-Guérin immunisation clinics in inner-city Lagos were enrolled into a universal hearing screening programme during which correlates of severe neonatal jaundice (requiring phototherapy and/or exchange blood transfusion) were explored with multivariable logistic regression.

RESULTS

Of the 5262 infants enrolled, only 48.7% were born in hospitals although almost all mothers (97.9%) attended antenatal clinics. 6.7% had a history of neonatal jaundice of whom 5.5% (95% CI:4.9-6.2) received phototherapy and 1.9% (95% CI:1.5-2.3) had an exchange blood transfusion. Factors independently associated with severe neonatal jaundice were maternal religion, occupation, use of herbal preparations during pregnancy, infant's gender, weight at screening, multiple gestation and place of birth. All but two infants with severe neonatal jaundice were exclusively breast-fed. Of those who failed the hearing tests, 17.3% were treated with phototherapy and 11.3% had an exchange blood transfusion. At least 8.9% of infants requiring phototherapy and 17.3% of those requiring exchange blood transfusion were at risk of sensorineural hearing loss.

CONCLUSIONS

Severe neonatal jaundice is a significant condition associated with modifiable risk factors in this population. Policy initiatives for prevention, early detection followed by appropriate and timely intervention are urgently needed to reduce the disease burden.

Pathogens associated with sepsis in newborns and young infants in developing countries

INTRODUCTION

Knowledge of pathogens causing infections in young infants (up to 90 days of life) is essential for devising community-based management strategies. Most etiological data from developing countries are hospital-based and may have little relevance to communities in which most babies are born at home.

METHODS

We searched the literature for studies from developing countries reporting etiology of community-acquired infections (sepsis, pneumonia, meningitis) published since 1980. Hospital-based studies reporting early onset sepsis, sepsis among babies admitted from, or born at home were included.

RESULTS

Of 63 studies, 13 focused on community-acquired infections, but limited data were available from home-born neonates. In the first week of life (3209 isolates), Klebsiella species (25%), Escherichia coli (15%), and Staphylococcus aureus (18%) were major pathogens. Group B streptococci (GBS) were relatively uncommon (7%), although regional differences existed. After the first week of life (835 isolates), S. aureus (14%), GBS (12%), Streptococcus pneumoniae (12%), and nontyphoidal Salmonella species (13%) were most frequent. S. pneumoniae (27%) was most common in the postneonatal period (among 141 isolates). Gram-negatives predominated (77%) among home-delivered babies (among 170 isolates).

CONCLUSIONS

Limited information is available on etiology of serious bacterial infections in community settings. Hospital-based studies suggest that most infections in the first week of life are due to Gram-negative pathogens, and many may be environmentally rather than maternally-acquired, owing to unhygienic delivery practices. Such practices may also explain the predominance of Gram-negative infections among home-born infants, although data from home settings are limited. These findings have implications for developing prevention and management strategies in communities and hospitals.

Population structure of human isolates of Streptococcus agalactiae from Dakar and Bangui

Multilocus sequence types of 163 human Streptococcus agalactiae strains isolated in Bangui and Dakar were analyzed. We identified local specificities in the distribution of sequence types and capsular serotypes. However, the overall population structure is similar to that in the United States and Europe, suggesting that few specific clones colonize humans.

Characteristics and outcome of cardiopulmonary resuscitation in hospitalised African children

Objective

To review the characteristics and outcome of cardiopulmonary resuscitation in children at a rural hospital in Kenya.

Patients and method

All children aged 0–14 years who experienced ≥1 episode of respiratory or cardiopulmonary arrest during April 2002–2004 were prospectively identified. Demographic variables, cause of hospitalisation, type and duration of arrest, resuscitation measures taken and outcomes were determined.

Results

114 children experienced at least one episode of respiratory arrest (RA) or cardiopulmonary arrest (CPA). Cardiopulmonary resuscitation (CPR) was performed on all children. “Do not resuscitate order” (DNR) was given in 15 patients after initial resuscitation. Eighty two patients (72%) had RA and 32 (28%) had CPA. 25/82 (30%) patients with RA survived initial CPR compared to 5/32 (16%) with CPA. Survival at discharge was 22% (18/82) in children who had RA while no one with CPA survived at discharge. The leading underlying diseases were severe malaria, septicaemia and severe malnutrition. Prolonged resuscitation beyond 15 min and receiving adrenaline [epinephrine] (at least one dose of 10 μg/kg IV) were predictive of poor final outcome.

Conclusion

Cardiopulmonary arrest after admission has a very poor prognosis in our hospital. Infectious diseases are the main underlying causes of arrest. If a child fails to respond to the basic tenements of PALS within 15 min then it is unlikely that further efforts to sustain life will be fruitful in hospitals where ventilation facilities are not present.

Induction and termination of inflammatory signaling in group B streptococcal sepsis

SUMMARY

Group B streptococcus (GBS) is part of the normal genital and gastrointestinal flora in healthy humans. However, GBS is a major cause of sepsis and meningitis in newborn infants in the Western world and an important pathogen in many developing countries. The dissection of the host response to GBS may increase the general understanding of innate immunity in sepsis, because newborn infants lack a sufficient adaptive response. Inflammatory signal induction in macrophages by GBS seems largely preserved in newborn infants, as shown both in vitro and in vivo. The engagement of Toll-like receptor 2 (TLR2) by lipoproteins and a myeloid differentiation factor 88 (MyD88)--dependent pathway induced by GBS cell wall are both important in this context. TLR2 activation of microglia by GBS induces neuronal damage, which might account for the high morbidity of GBS meningitis. At the same time, TLR2 mediates activation-induced cell death (AICD), a process involved in the containment of inflammation. In newborn infants, AICD and anti-bacterial polymorphonuclear leukocyte activity appears to be compromised. Accordingly, neonatal aberrations in the pathogen-specific negative control of inflammatory signaling are likely to contribute to excessive inflammation and neurological sequelae in GBS sepsis and meningitis.

Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya

The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.

Clinico-epidemiological profile and predictors of severe illness in young infants (0-59 days) in Ghana

BACKGROUND

Young infant mortality has remained high and relatively unchanged compared with deaths of older infants. Strategies to reduce infant mortality, however, are mostly targeted at the older child.

OBJECTIVES

To describe the clinical profile of sick young infants presenting to a hospital and to define important signs and symptoms that will enable health workers to detect young infants with severe illness requiring hospital admission.

METHODS

Young infants aged 0-59 days presenting to a paediatric out-patient clinic were evaluated by a nurse using a standardised list of signs and symptoms. A paediatrician independently evaluated these children and decided whether they needed hospitalisation.

RESULTS

A total of 685 young infants were enrolled, 22% of whom were <7 days of age. The commonest reasons for seeking care were jaundice in the 0-6-day group, skin problems in the 7-27-day group and cough in the 28-59-day group. The primary clinical diagnoses for admissions were sepsis in the 0-6- and 7-27-day groups and pneumonia in the 28-59-day group. Clinical signs and symptoms predicting severe illness requiring admission were general (history of fever, difficult feeding, not feeding well and temperature >37.5 degrees C) and respiratory (respiratory rate > or =60/min, severe chest in-drawing).

CONCLUSION

General and respiratory signs are important predictors for severe illness in young infants. Training peripheral health workers to recognise these signs and to refer to hospital for further assessment and management might have a significant impact on young infant mortality.

Incidence and clinical characteristics of group A rotavirus infections among children admitted to hospital in Kilifi, Kenya

BACKGROUND

Rotavirus, predominantly of group A, is a major cause of severe diarrhoea worldwide, with the greatest burden falling on young children living in less-developed countries. Vaccines directed against this virus have shown promise in recent trials, and are undergoing effectiveness evaluation in sub-Saharan Africa. In this region limited childhood data are available on the incidence and clinical characteristics of severe group A rotavirus disease. Advocacy for vaccine intervention and interpretation of effectiveness following implementation will benefit from accurate base-line estimates of the incidence and severity of rotavirus paediatric admissions in relevant populations. The study objective was to accurately define the incidence and severity of group A rotavirus disease in a resource-poor setting necessary to make informed decisions on the need for vaccine prevention.

METHODS AND FINDINGS

Between 2002 and 2004 we conducted prospective surveillance for group A rotavirus infection at Kilifi District Hospital in coastal Kenya. Children < 13 y of age were eligible as "cases" if admitted with diarrhoea, and "controls" if admitted without diarrhoea. We calculated the incidence of hospital admission with group A rotavirus using data from a demographic surveillance study of 220,000 people in Kilifi District. Of 15,347 childhood admissions 3,296 (22%) had diarrhoea, 2,039 were tested for group A rotavirus antigen and, of these, 588 (29%) were positive. 372 (63%) rotavirus-positive cases were infants. Of 620 controls 19 (3.1%, 95% confidence interval [CI] 1.9-4.7) were rotavirus positive. The annual incidence (per 100,000 children) of rotavirus-positive admissions was 1,431 (95% CI 1,275-1,600) in infants and 478 (437-521) in under-5-y-olds, and highest proximal to the hospital. Compared to children with rotavirus-negative diarrhoea, rotavirus-positive cases were less likely to have coexisting illnesses and more likely to have acidosis (46% versus 17%) and severe electrolyte imbalance except hyponatraemia. In-hospital case fatality was 2% among rotavirus-positive and 9% among rotavirus-negative children.

CONCLUSIONS

In Kilifi > 2% of children are admitted to hospital with group A rotavirus diarrhoea in the first 5 y of life. This translates into over 28,000 vaccine-preventable hospitalisations per year across Kenya, and is likely to be a considerable underestimate. Group A rotavirus diarrhoea is associated with acute life-threatening metabolic derangement in otherwise healthy children. Although mortality is low in this clinical research setting this may not be generally true in African hospitals lacking rapid and appropriate management.

What are the implications for childhood pneumonia of successfully introducing Hib and pneumococcal vaccines in developing countries?

The authors look to the future and imagine the implications of a successful vaccination campaign againstH. influenzae type b and pneumococcus.

The decline in paediatric malaria admissions on the coast of Kenya

Background

There is only limited information on the health impact of expanded coverage of malaria control and preventative strategies in Africa.

Methods

Paediatric admission data were assembled over 8.25 years from three District Hospitals; Kilifi, Msambweni and Malindi, situated along the Kenyan Coast. Trends in monthly malaria admissions between January 1999 and March 2007 were analysed using several time-series models that adjusted for monthly non-malaria admission rates and the seasonality and trends in rainfall.

Results

Since January 1999 paediatric malaria admissions have significantly declined at all hospitals. This trend was observed against a background of rising or constant non-malaria admissions and unaffected by long-term rainfall throughout the surveillance period. By March 2007 the estimated proportional decline in malaria cases was 63% in Kilifi, 53% in Kwale and 28% in Malindi. Time-series models strongly suggest that the observed decline in malaria admissions was a result of malaria-specific control efforts in the hospital catchment areas.

Conclusion

This study provides evidence of a changing disease burden on the Kenyan coast and that the most parsimonious explanation is an expansion in the coverage of interventions such as the use of insecticide-treated nets and the availability of anti-malarial medicines. While specific attribution to intervention coverage cannot be computed what is clear is that this area of Kenya is experiencing a malaria epidemiological transition.

Young infant sepsis: aetiology, antibiotic susceptibility and clinical signs

Globally, young infant mortality comprises 40% of the estimated 10.8 million child deaths annually. Almost all (99%) of these deaths arise in low- and middle-income countries (LMICs). Achievement of the Millennium Development Goal for child survival, however, requires a significant improvement in the management of infections in young infants. We have reviewed current evidence from LMICs on one major cause of young infant mortality, severe infection, and have described the range of pathogens, reported antibiotic susceptibility and value of clinical signs in identifying severe bacterial illness. Evidence from the reviewed studies appears to show that common pathogens in young infant infections change over time and vary within and across settings. However, there are few good, large studies outside major urban settings and many reports describe infections of babies born in hospital when most young infant infections probably occur in the majority born at home. Yet what knowledge there is can aid in instituting prompt and appropriate therapy, and perhaps thus minimize the emergence of multidrug-resistant bacteraemia, a major threat at least in hospital settings. Improved country level data on pattern of microorganisms, resistance and antibiotic use are required to help reduce mortality through development of local, evidence-based clinical guidelines.

Invasive group B streptococcal infection in infants, Malawi

Group B streptococci (GBS) are a recently identified cause of neonatal sepsis in Malawi. In Queen Elizabeth Central Hospital, Blantyre, Malawi, during May 2004-June 2005, GBS were isolated from routine blood and cerebrospinal fluid cultures from 57 infants. The incidence of early (EOD) and late onset (LOD) invasive GBS disease was 0.92 and 0.89 cases per 1,000 live births, respectively. Sepsis (52%) was the most common manifestation of EOD; meningitis (43%) and sepsis (36%) were the principal manifestations of LOD. The case-fatality rate was 33% overall (38% EOD, 29% LOD). Serotypes Ia and III were responsible for 77% of disease. All isolates were susceptible to penicillin, but 21% were resistant to erythromycin. The rate and manifestations of neonatal GBS disease in Malawi are similar to those in industrialized countries, but the case-fatality rate is higher than in industrialized countries. Effective locally relevant prevention strategies are needed.

Bacterial pneumonia vaccines and childhood pneumonia: are we winning, refining, or redefining?

Bacterial pneumonia is a substantial cause of childhood morbidity and mortality worldwide, but determination of pathogen-specific burden remains a challenge. In less developed settings, the WHO recommended guidelines are useful for initiating care, but are non-specific. Blood culture has low sensitivity, while radiological findings are non-specific and do not discriminate between viral and bacterial causes of pneumonia. In vaccine probe studies, efficacy is dependent on the specificity of the study outcome to detect pneumonia and the impact of the vaccine on the selected outcome, and may underestimate the true burden of bacterial pneumonia. The rising incidence of antibiotic resistance, emerging respiratory pathogens, potential replacement pneumococcal disease following widespread introduction of pneumococcal polysaccharide-protein conjugate vaccine, the limited specificity of chest radiography, and the poor sensitivity of blood culture are substantial obstacles to accurate surveillance. We provide an overview of the diagnostic challenges of bacterial pneumonia and highlight the need for refining the current diagnostic approach to ensure adequate epidemiological surveillance of childhood pneumonia and the success, or otherwise, of any immunisation strategies.

Neurological and developmental outcome of neonatal jaundice and sepsis in rural Kenya

Neonatal jaundice (NJ) and sepsis are common causes of neonatal mortality in sub-Saharan Africa, but little is known about the long-term morbidity in this setting. This study aimed to describe the neurological and developmental sequelae of severe neonatal hyperbilirubinaemia and neonatal sepsis (NS) in a district hospital in rural Kenya. Twenty-three term infants with NJ [total serum bilirubin (TSB) >300 mumol/l] and 24 infants with a history of NS were identified from hospital records. These children were compared to 40 children from the community (CC) without neonatal problems. At ages 18-32 months, the children's neurological, motor and developmental status were assessed, and blood groups of the NJ and NS subjects and their mothers were determined. Ten (43%) of the NJ subjects were unable to sit and/or stand independently. The NJ subjects had significantly more neurological, motor and developmental difficulties and caused greater maternal concern than the CCs. Five (21%) of the NJ subjects had possible blood group incompatibility. The NS subjects had significantly more motor and eye-hand difficulties and maternal concerns expressed than the CCs. Severe NJ in term infants (of mainly non-haemolytic origin) was associated with a high prevalence of neurological and developmental sequelae at ages 18-32 months. The NS is also associated with neuro-developmental sequelae, but the pattern is different to those seen in NJ. Since NS is common in resource poor countries, this may be an important cause of neuro-developmental impairment in children living in this setting.

Aetiology of neonatal sepsis in Blantyre, Malawi: 1996-2001

AIM

The aim of this retrospective study was to report causes, antibiotic resistance and outcome of neonatal sepsis (often fatal in developing countries) in Malawi.

METHODS

All blood and cerebrospinal fluid isolates collected between January 1996 and December 2001 from inpatients aged 0-30 days with suspected sepsis at Queen Elizabeth Central Hospital, Blantyre, Malawi were reviewed. In vitro resistance to antibiotics commonly used in Malawi was assessed. Case fatality rate was analysed with respect to age, bacterial pathogen and infection site.

RESULTS

A total of 801 bacteria were isolated from 784 neonates over 6 years-599 isolates from blood and 202 from cerebrospinal fluid. Overall, 54% of bacteria were gram-positive and 46% gram-negative. The commonest causes of neonatal sepsis were group B Streptococcus (17%) and non-typhoidal Salmonella (14%). In vitro antibiotic susceptibility to the first-line antibiotic combination of penicillin and gentamicin was 78% for all isolates, but in vitro sensitivities to gentamicin for Klebsiella spp and non-typhoidal Salmonella were only 33% and 53%, respectively. In-hospital case fatality rate was known for only 301 cases and was high at 48%. Group B Streptococcus was associated with the best outcome. Mortality was significantly higher if presentation was in the 1st week of life or if sepsis was caused by gram-negative bacteria. The causes of neonatal sepsis in this population show a different pattern from other studies in developing countries.

Neonatal pneumonia in developing countries

Pneumonia contributes to between 750,000 and 1.2 million neonatal deaths and an unknown number of stillbirths each year world wide. The aetiology depends on time of onset. Gram negative bacilli predominate in the first week of life, and Gram positive bacteria after that. Streptococcus pneumoniae probably causes about 25% of neonatal pneumonia. Interventions that would reduce mortality from this condition would have a large range of beneficial effects: improved maternal health, better management of other common neonatal conditions, and reduced long term childhood and adult morbidity.

Early infant growth monitoring - time well spent?

BACKGROUND

In sub-Saharan Africa, growth monitoring for every infant consumes time and resources with no evidence of any benefits. We consider an alternative pragmatic approach which provides scheduled monitoring for low birth weight infants only, and takes advantage of non-routine clinic visits for normal birth weight infants. We investigate the implications for the number of weighing episodes and performance as a screening tool using data from a cohort study of infants followed-up from birth to 98 days.

METHODS

Babies delivered in a Kenyan district hospital and enrolled in a birth cohort were weighed at birth and at follow-up visits coinciding with their immunizations at 6, 10 and 14 weeks. Episodes of illness resulting in clinic visits, hospital admissions or death were identified and recorded.

RESULTS

Four-fifths (81%) of the 2210 babies weighed 2500 g or more at birth, of whom 133 (7%) were admitted to hospital or died before 14 weeks of age. 85% of the deaths and 67% of admissions occurred within 3 weeks of birth. Most babies weighing 2500 g or more and who had weight measurements grew well. Only 4% of infants were exclusively breastfed at 14 weeks of age. Neither universal nor pragmatic growth monitoring was a good screening tool among this group of infants for episodes of illness in the short-term. Pragmatic monitoring would involve 72% fewer weighing episodes.

CONCLUSIONS

A pragmatic approach in early infancy would not represent a major change in policy, would appear to have no disadvantages and would probably increase the time available for implementing interventions of greater benefit such as breastfeeding promotion.

The management of sick young infants at primary health centres in a rural developing country

AIMS

To investigate the epidemiology of illness among young infants at remote health clinics in a rural developing country, and to determine risk factors for mortality that might be used as triggers for emergency treatment or referral.

METHODS

Multi-site 12 month observational study of consecutive presentations of infants less than 2 months, and an investigation of neonates who died in one district without accessing health care.

RESULTS

Forty per cent of 511 young infant presentations occurred in the first week of life and most of these in the first 24 hours. Twenty five deaths were recorded: 18 in the health facilities and seven in villages. In addition there were eight stillbirths. Clinical signs predicting death were: not able to feed, fast respiratory rate, apnoea, cyanosis, "too small", "skin-cold", and severe abdominal distension. Signs indicating severe respiratory compromise were present in 25% of young infants; failure to give oxygen therapy was a modifiable factor in 27% of deaths within health facilities. A high proportion of seriously ill young infants were discharged from health facilities early without adequate follow up. A common reason for not seeking care for fatally ill neonates was the perception by parents that health staff would respond negatively to their social circumstances.

CONCLUSIONS

Clinical signs with moderate positive predictive value for death may be useful triggers for emergency treatment and longer observation or urgent referral. The results of this study may be useful in planning strategies to address high neonatal mortality rates in developing countries.

Delivery of paediatric care at the first-referral level in Kenya

We aimed to investigate provision of paediatric care in government district hospitals in Kenya. We surveyed 14 first-referral level hospitals from seven of Kenya's eight provinces and obtained data for workload, outcome of admission, infrastructure, and resources and the views of hospital staff and caretakers of admitted children. Paediatric admission rates varied almost ten-fold. Basic anti-infective drugs, clinical supplies, and laboratory tests were available in at least 12 hospitals, although these might be charged for on discharge. In at least 11 hospitals, antistaphylococcal drugs, appropriate treatment for malnutrition, newborn feeds, and measurement of bilirubin were rarely or never available. Staff highlighted infrastructure and human and consumable resources as problems. However, a strong sense of commitment, support for the work of the hospital, and a desire for improvement were expressed. Caretakers' views were generally positive, although dissatisfaction with the physical environment in which care took place was common. The capacity of the district hospital in Kenya needs strengthening by comprehensive policies that address real needs if current or new interventions and services at this level of care are to enhance child survival.

Hemolytic disease due to membrane ion channel disorders

PURPOSE OF REVIEW

To summarize recent findings in the study of the 'hereditary stomatocytoses and allied disorders', diseases in which the red cell membrane leaks Na and K, disturbing the osmotic homeostasis of the cell.

RECENT FINDINGS

Recent work has emphasized the diversity of these conditions, especially evident in the variations in temperature dependence of the cation leak. The association between the dehydrated, xerocytic form that maps to chromosome 16, with perinatal ascites is confirmed. Two cases that may represent a new hematoneurologic syndrome have been recognized.

SUMMARY

These leaky-membrane diseases fall into three main categories. The 'dehydrated' or xerocytic form maps to chromosome 16 and shows a minimal leak, and can show an excess of phosphatidylcholine in the membrane. Some of these xerocytic cases show a syndrome of self-limiting perinatal ascites of unknown cause. A second group shows very variable temperature dependence in the cation leak. The most severe 'overhydrated' form shows very leaky cells and the 32 kD stomatin protein is missing, although the gene is not mutated. This deficiency seems to be the result of a trafficking problem. The protein is associated with cholesterol and sphingomyelin-rich 'rafts' and may be some kind of partner protein for a membrane-bound proteolytic system.

Serious bacterial infections in newborn infants in developing countries

PURPOSE OF REVIEW

The overwhelming majority of the world's annual 4 million neonatal deaths occur in developing countries. This review therefore briefly addresses the burden, aetiology, prevention and management of serious neonatal bacterial infections in low-income settings.

RECENT FINDINGS

Bacterial infection is the biggest cause of neonatal admissions to hospitals, and probably the biggest cause of morbidity in the community, but its burden is unclear. The commonest serious infections involve bacteraemia, meningitis and respiratory infection, and case fatality rates may be as high as 45%. Key pathogens are Escherichia coli, Klebsiella species, Staphylococcus aureus and Streptococcus pyogenes. The incidence of neonatal infections with group B streptococcus is highly variable, as is the spectrum of antimicrobial resistance.

SUMMARY

Current areas of research include the rectification of micronutrient deficiencies, neonatal skin care, appropriate breastfeeding recommendations, cleansing of the birth canal, and simplified methods of diagnosis of infection. Operational activities include the control of neonatal tetanus, the diagnosis and treatment of sexually transmitted infections, integrated strategies for improving pregnancy, childbirth and neonatal survival, community-based management of acute respiratory infections, and community-based management of neonatal sepsis.