Inter-observer variation in the assessment of clinical signs in sick Tanzanian children

Use of the ReSVinet Scale for parents and healthcare workers in a paediatric emergency service: a prospective study

INTRODUCTION

Most scales for acute respiratory infection (ARI) are limited to healthcare worker (HCW) use for clinical decision-making. The Respiratory Syncytial Virus network (ReSVinet) Scale offers a version for parents that could potentially help as an early warning system.

OBJECTIVE

To determine whether or not the ReSVinet Scale for ARI in infants can be reliably used by HCWs and parents in an emergency service.

METHODS

A prospective study was done of infants with ARI who were admitted to a paediatric emergency room to assess the ReSVinet Scale when used by faculty (paediatric doctor-professors), residents (doctors doing their first specialty in paediatrics) and parents. Spearman's correlation and a weighted kappa coefficient were used to measure interobserver agreement. Internal consistency was also tested by Cronbach's alpha test.

RESULTS

Overall, 188 patients, 58% male, were enrolled. A Spearman's correlation of 0.92 for faculty and resident scoring and 0.64 for faculty or resident and parent scoring was found. The weighted kappa coefficients were 0.78 for faculty versus residents, 0.41 for faculty versus parents, and 0.41 for residents versus parents. Cronbach's alpha test was 0.67 for faculty, 0.62 for residents and 0.69 for parents.

CONCLUSION

There was good correlation in the ReSVinet scores between health professionals when used in the paediatric emergency area. Agreement between parents and health professionals was found to be more variable. Future studies should focus on finding ways to improve its reliability when used by parents before the scale is used in the emergency room.

Impact of the change in WHO's severe pneumonia case definition on hospitalized pneumonia epidemiology: case studies from six countries

OBJECTIVE

To quantify the impact of the change in definition of severe pneumonia on documented pneumonia burden.

METHODS

We reviewed existing data acquired during observational hospitalized pneumonia studies, before the introduction of the pneumococcal conjugate vaccine, in infants aged 2-23 months from Fiji, Gambia, Lao People's Democratic Republic, Malawi, Mongolia and Viet Nam. We used clinical data to calculate the percentage of all-cause pneumonia hospitalizations with severe pneumonia, and with primary end-point consolidation, according to both the 2005 or 2013 World Health Organization (WHO) definitions. Where population data were available, we also calculated the incidence of severe pneumonia hospitalizations according to the different definitions.

FINDINGS

At six of the seven sites, the percentages of all-cause pneumonia hospitalizations due to severe pneumonia were significantly less (P < 0.001) according to the 2013 WHO definition compared with the 2005 definition. However, the percentage of severe pneumonia hospitalizations, according to the two definitions of severe pneumonia, with primary end-point consolidation varied little within each site. The annual incidences of severe pneumonia hospitalizations per 100 000 infants were significantly less (all P < 0.001) according to the 2013 definition compared with the 2005 definition, ranging from a difference of -301.0 (95% confidence interval, CI: -405.2 to -196.8) in Fiji to -3242.6 (95% CI: -3695.2 to -2789.9) in the Gambia.

CONCLUSION

The revision of WHO's definition of severe pneumonia affects pneumonia epidemiology, and hence the interpretation of any pneumonia intervention impact evaluation.

Can the use of digital algorithms improve quality care? An example from Afghanistan

BACKGROUND

Quality of care is a difficult parameter to measure. With the introduction of digital algorithms based on the Integrated Management of Childhood Illness (IMCI), we are interested to understand if the adherence to the guidelines improved for a better quality of care for children under 5 years old.

METHODS

More than one year after the introduction of digital algorithms, we carried out two cross sectional studies to assess the improvements in comparison with the situation prior to the implementation of the project, in two Basic Health Centres in Kabul province. One survey was carried out inside the consultation room and was based on the direct observation of 181 consultations of children aged 2 months to 5 years old, using a checklist completed by a senior physicians. The second survey queried 181 caretakers of children outside the health facility for their opinion about the consultation carried out through the tablet and prescriptions and medications given.

RESULTS

We measured the quality of care as adherence to the IMCI's guidelines. The study evaluated the quality of the physical examination and the therapies prescribed with a special attention to antibiotic prescription. We noticed a dramatic improvement (p<0.05) of several indicators following the introduction of digital algorithms. The baseline physical examination was appropriate only for 23.8% [IC% 19.9-28.1] of the patients, 34.5% [IC% 30.0-39.2] received a correct treatment and 86.1% [IC% 82.4-89.2] received at least one antibiotic. With the introduction of digital algorithms, these indicators statistically improved respectively to 84.0% [IC% 77.9-88.6], >85% and less than 30%.

CONCLUSIONS

Our findings suggest that digital algorithms improve quality of care by applying the guidelines more effectively. Our experience should encourage to test this tool in different settings and to scale up its use at province/state level.

Standardization of Clinical Assessment and Sample Collection Across All PERCH Study Sites

Background.

Variable adherence to standardized case definitions, clinical procedures, specimen collection techniques, and laboratory methods has complicated the interpretation of previous multicenter pneumonia etiology studies. To circumvent these problems, a program of clinical standardization was embedded in the Pneumonia Etiology Research for Child Health (PERCH) study.

Methods.

Between March 2011 and August 2013, standardized training on the PERCH case definition, clinical procedures, and collection of laboratory specimens was delivered to 331 clinical staff at 9 study sites in 7 countries (The Gambia, Kenya, Mali, South Africa, Zambia, Thailand, and Bangladesh), through 32 on-site courses and a training website. Staff competency was assessed throughout 24 months of enrollment with multiple-choice question (MCQ) examinations, a video quiz, and checklist evaluations of practical skills.

Results.

MCQ evaluation was confined to 158 clinical staff members who enrolled PERCH cases and controls, with scores obtained for >86% of eligible staff at each time-point. Median scores after baseline training were ≥80%, and improved by 10 percentage points with refresher training, with no significant intersite differences. Percentage agreement with the clinical trainer on the presence or absence of clinical signs on video clips was high (≥89%), with interobserver concordance being substantial to high (AC1 statistic, 0.62–0.82) for 5 of 6 signs assessed. Staff attained median scores of >90% in checklist evaluations of practical skills.

Conclusions.

Satisfactory clinical standardization was achieved within and across all PERCH sites, providing reassurance that any etiological or clinical differences observed across the study sites are true differences, and not attributable to differences in application of the clinical case definition, interpretation of clinical signs, or in techniques used for clinical measurements or specimen collection.

Variability of respiratory rate measurements in children suspected with non-severe pneumonia in north-east Tanzania

OBJECTIVE

Measurement of respiratory rate is an important clinical sign in the diagnosis of pneumonia but suffers from interobserver variation. Here, we assess the use of video recordings as a quality assurance tool that could be useful both in research and in training of staff.

METHODS

Respiratory rates (RR) were recorded in children aged 2-59 months presenting with cough or difficulty breathing at two busy outpatient clinics in Tanzania. Measurements were repeated at 10-min intervals in a quiet environment with simultaneous video recordings that were independently reviewed by two paediatricians.

RESULTS

Eight hundred and fifty-nine videos were sent to two paediatricians; 148 (17.2%) were considered unreadable by one or both. For the 711 (82.8%) videos that were readable by both paediatricians, there was perfect agreement for the presence of raised RR with a kappa value (κ) of 0.85 (P < 0.001); and in 476 (66.9%) cases, both paediatricians agreed on the RR within 2 breaths per minute (±2 bpm). A reported illness of 5 days or more was associated with unreadable video recordings (OR = 3.44, CI: 1.5-6.08; P < 0.001). The multilevel model showed that differences between observers accounted for only 13% of the variability in RR.

CONCLUSION

Video recordings are reliable tools for quality assurance of RR measurements in children with suspected pneumonia. Videos with a clear view of respiratory movements may also be useful in training primary healthcare staff.

A Review of Methods to Detect Cases of Severely Malnourished Children in the Community for Their Admission into Community-Based Therapeutic Care Programs

Background

The complexity and cost of measuring weight-for-height make it unsuitable for use by community-based volunteers. This has led community therapeutic care programs to adopt a two-stage screening and admission procedure in which mid-upper-arm circumference (MUAC) is used for referral and weight-for-height is used for admission. Such a procedure results in many individuals being referred for care on the basis of MUAC but subsequently being refused treatment because they do not meet the weight-for-height admission criterion. This “problem of rejected referrals” has proved to be a major barrier to program uptake.

Objective

To systematically review methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs.

Methods

Clinical and anthropometric methods for case detection of severely malnourished children in the community were reviewed with regard to their ability to reflect both mortality risk and nutritional status.

Results

MUAC, with the addition of the presence of bipedal edema, was found to be the indicator best suited to screening and case detection of malnutrition in the community. The case definition “MUAC < 110 mm OR the presence of bipedal edema,” with MUAC measured by a color-banded strap, is suitable for screening and case detection of malnutrition in the community for children aged between 6 and 59 months. Monitoring and discharge criteria were also reviewed.

Conclusions

There is no compelling evidence to support a move away from using weight in combination with clinical criteria for monitoring and discharge.

Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi

OBJECTIVE

To investigate implementation of outpatient pulse oximetry among children with pneumonia, in Malawi.

METHODS

In 2011, 72 health-care providers at 18 rural health centres and 38 community health workers received training in the use of pulse oximetry to measure haemoglobin oxygen saturations. Data collected, between 1 January 2012 and 30 June 2014 by the trained individuals, on children aged 2-59 months with clinically diagnosed pneumonia were analysed.

FINDINGS

Of the 14 092 children included in the analysis, 13 266 (94.1%) were successfully checked by oximetry. Among the children with chest indrawing and/or danger signs, those with a measured oxygen saturation below  90% were more than twice as likely to have been referred as those with higher saturations (84.3% [385/457] vs 41.5% [871/2099]; P < 0.001). The availability of oximetry appeared to have increased the referral rate for severely hypoxaemic children without chest indrawing or danger signs from 0% to 27.2% (P < 0.001). In the absence of oximetry, if the relevant World Health Organization (WHO) guidelines published in 2014 had been applied, 390/568 (68.7%) severely hypoxaemic children at study health centres and 52/84 (61.9%) severely hypoxaemic children seen by community health workers would have been considered ineligible for referral.

CONCLUSION

Implementation of pulse oximetry by our trainees substantially increased the referrals of Malawian children with severe hypoxaemic pneumonia. When data from oximetry were excluded, retrospective application of the guidelines published by WHO in 2014 failed to identify a considerable proportion of severely hypoxaemic children eligible only via oximetry.

Predictors of treatment failure for non-severe childhood pneumonia in developing countries--systematic literature review and expert survey--the first step towards a community focused mHealth risk-assessment tool?

Background

Improved referral algorithms for children with non-severe pneumonia at the community level are desirable. We sought to identify predictors of oral antibiotic failure in children who fulfill the case definition of World Health Organization (WHO) non-severe pneumonia. Predictors of greatest interest were those not currently utilized in referral algorithms and feasible to obtain at the community level.

Methods

We systematically reviewed prospective studies reporting independent predictors of oral antibiotic failure for children 2–59 months of age in resource-limited settings with WHO non-severe pneumonia (either fast breathing for age and/or lower chest wall indrawing without danger signs), with an emphasis on predictors not currently utilized for referral and reasonable for community health workers. We searched PubMed, Cochrane, and Embase and qualitatively analyzed publications from 1997–2014. To supplement the limited published evidence in this subject area we also surveyed respiratory experts.

Results

Nine studies met criteria, seven of which were performed in south Asia. One eligible study occurred exclusively at the community level. Overall, oral antibiotic failure rates ranged between 7.8-22.9 %. Six studies found excess age-adjusted respiratory rate (either WHO-defined very fast breathing for age or 10–15 breaths/min faster than normal WHO age-adjusted thresholds) and four reported young age as predictive for oral antibiotic failure. Of the seven predictors identified by the expert panel, abnormal oxygen saturation and malnutrition were most highly favored per the panel’s rankings and comments.

Conclusions

This review identified several candidate predictors of oral antibiotic failure not currently utilized in childhood pneumonia referral algorithms; excess age-specific respiratory rate, young age, abnormal oxygen saturation, and moderate malnutrition. However, the data was limited and there are clear evidence gaps; research in rural, low-resource settings with community health workers is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0392-x) contains supplementary material, which is available to authorized users.

Effect of context on respiratory rate measurement in identifying non-severe pneumonia in African children

Objective

Cough or difficult breathing and an increased respiratory rate for their age are the commonest indications for outpatient antibiotic treatment in African children. We aimed to determine whether respiratory rate was likely to be transiently raised by a number of contextual factors in a busy clinic leading to inaccurate diagnosis.

Methods

Respiratory rates were recorded in children aged 2–59 months presenting with cough or difficulty breathing to one of the two busy outpatient clinics and then repeated at 10‐min intervals over 1 h in a quiet setting.

Results

One hundred and sixty‐seven children were enrolled with a mean age of 7.1 (SD ± 2.9) months in infants and 27.6 (SD ± 12.8) months in children aged 12–59 months. The mean respiratory rate declined from 42.3 and 33.6 breaths per minute (bpm) in the clinic to 39.1 and 32.6 bpm after 10 min in a quiet room and to 39.2 and 30.7 bpm (P < 0.001) after 60 min in younger and older children, respectively. This resulted in 11/13 (85%) infants and 2/15 (13%) older children being misclassified with non‐severe pneumonia. In a random effects linear regression model, the variability in respiratory rate within children (42%) was almost as much as the variability between children (58%). Changing the respiratory rates cut‐offs to higher thresholds resulted in a small reduction in the proportion of non‐severe pneumonia mis‐classifications in infants.

Conclusion

Noise and other contextual factors may cause a transient increase in respiratory rate and consequently misclassification of non‐severe pneumonia. However, this effect is less pronounced in older children than infants. Respiratory rate is a difficult sign to measure as the variation is large between and within children. More studies of the accuracy and utility of respiratory rate as a proxy for non‐severe pneumonia diagnosis in a busy clinic are needed.

Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI)

BACKGROUND

More than three decades after the 1978 Declaration of Alma-Ata enshrined the goal of 'health for all', high-quality primary care services remain undelivered to the great majority of the world's poor. This failure to effectively reach the most vulnerable populations has been, in part, a failure to develop and implement appropriate and effective primary care delivery models. This paper examines a root cause of these failures, namely that the inability to achieve clear and practical consensus around the scope and aims of primary care may be contributing to ongoing operational inertia. The present work also examines integrated models of care as a strategy to move beyond conceptual dissonance in primary care and toward implementation. Finally, this paper examines the strengths and weaknesses of a particular model, the World Health Organization's Integrated Management of Adolescent and Adult Illness (IMAI), and its potential as a guidepost toward improving the quality of primary care delivery in poor settings.

DISCUSSION

Integration and integrated care may be an important approach in establishing a new paradigm of primary care delivery, though overall, current evidence is mixed. However, a number of successful specific examples illustrate the potential for clinical and service integration to positively impact patient care in primary care settings. One example deserving of further examination is the IMAI, developed by the World Health Organization as an operational model that integrates discrete vertical interventions into a comprehensive delivery system encompassing triage and screening, basic acute and chronic disease care, basic prevention and treatment services, and follow-up and referral guidelines. IMAI is an integrated model delivered at a single point-of-care using a standard approach to each patient based on the universal patient history and physical examination. The evidence base on IMAI is currently weak, but whether or not IMAI itself ultimately proves useful in advancing primary care delivery, it is these principles that should serve as the basis for developing a standard of integrated primary care delivery for adults and adolescents that can serve as the foundation for ongoing quality improvement.

SUMMARY

As integrated primary care is the standard of care in the developed world, so too must we move toward implementing integrated models of primary care delivery in poorer settings. Models such as IMAI are an important first step in this evolution. A robust and sustained commitment to innovation, research and quality improvement will be required if integrated primary care delivery is to become a reality in developing world.

Baseline assessment of adult and adolescent primary care delivery in Rwanda: an opportunity for quality improvement

BACKGROUND

As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda.

METHODS

Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard.

RESULTS

Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively).

CONCLUSION

Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.

Multicenter study of hypoxemia prevalence and quality of oxygen treatment for hospitalized Malawian children

BACKGROUND

Although hypoxemic children have high mortality, little is known about hypoxemia prevalence and oxygen administration in African hospitals. We aimed to determine the hypoxemia prevalence and quality of oxygen treatment by local clinicians for hospitalized Malawian children.

METHODS

The study was conducted in five Malawian hospitals during January-April 2011. We prospectively measured the peripheral oxygen saturation (SpO(2)) using pulse oximetry for all children <15 years old and also determined clinical eligibility for oxygen treatment using WHO criteria for children <5 years old. We determined oxygen treatment quality by Malawian clinicians by comparing their use of WHO criteria for patients <5 years old using two standards: hypoxemia (SpO(2) <90%) and the use of WHO criteria by study staff.

RESULTS

Forty of 761 (5.3%) hospitalized children <15 years old had SpO(2) <90%. No hospital used pulse oximetry routinely, and only 9 of 40 (22.5%) patients <15 years old with SpO(2) <90% were treated with oxygen by hospital staff. Study personnel using WHO criteria for children <5 years old achieved a higher sensitivity (40.0%) and lower specificity (82.7%) than Malawian clinicians (sensitivity 25.7%, specificity 94.1%).

CONCLUSION

Although hypoxemia is common, the absence of routine pulse oximetry results in most hospitalized, hypoxemic Malawian children not receiving available oxygen treatment.

Do children with uncomplicated severe acute malnutrition need antibiotics? A systematic review and meta-analysis

BACKGROUND

Current (1999) World Health Organization guidelines recommend giving routine antibiotics (AB) for all children with severe acute malnutrition (SAM), even if they have uncomplicated disease with no clinically obvious infections. We examined the evidence behind this recommendation.

METHODS AND FINDINGS

OVID-MEDLINE, EMBASE, COCHRANE, GLOBAL-HEALTH, CINAHL, POPLINE, AFRICA-WIDE-NiPAD, and LILACS were searched for AB efficacy, bacterial resistance, and infection rates in SAM. Following PRISMA guidelines, a systematic review and meta-analysis were performed. Three randomised controlled trials (RCT), five Cochrane reviews, and 37 observational studies were identified. One cohort-study showed no increase in nutritional-cure and mortality in uncomplicated SAM where no AB were used. (p>0.05). However, an unpublished RCT in this setting did show mortality benefits. Another RCT did not show superiority of ceftriaxone over amoxicilllin for these same outcomes, but adressed SAM children with and without complications (p = 0.27). Another RCT showed no difference between amoxicillin and cotrimoxazole efficacies for pneumonia in underweight, but not SAM. Our meta-analysis of 12 pooled susceptibility-studies for all types of bacterial isolates, including 2767 stricly SAM children, favoured amoxicillin over cotrimoxazole for susceptibility medians: 42% (IQR 27-55%) vs 22% (IQR 17-23%) and population-weighted-means 52.9% (range 23-57%) vs 35.4% (range 6.7-42%). Susceptibilities to second-line AB were better, above 80%. Prevalence of serious infections in SAM, pooled from 24 studies, ranged from 17% to 35.2%. No study infered any association of infection prevalence with AB regimens in SAM.

CONCLUSIONS

The evidence underlying current antibiotic recommendations for uncomplicated SAM is weak. Susceptibility-studies favour amoxicillin over cotrimoxazole. However, given that these antibiotics have side-effects, costs, and risks as well as benefits, their routine use needs urgent testing. With reliable monitoring, we believe that there is sufficient equipoise for placebo controlled RCTs, the only robust way to demonstrate true efficacy.

Clinical algorithms for the identification of sick newborns in community-based settings

Clinical algorithms can be powerful tools for the identification of sick newborns at risk of neonatal mortality. Several studies have evaluated clinical signs for newborns aged 0-60 days to identify severe illness; however, few studies have focused specifically on the most vulnerable time period for neonatal death, the first week of life. Therefore, we reviewed the studies that evaluated clinical signs in newborns 0-60 days, focusing on infants 0 to <7 days. Based on a comparison of relevant studies, we then identified the common, important clinical signs shown to be useful for the identification of at-risk newborns by health workers in community-based and low-resource settings.

CONCLUSION

We concluded that further work is urgently needed to develop a clinical algorithm for widespread validation in various community-based settings, which focuses specifically on newborns <7 days at risk of early neonatal mortality.

The definition of pneumonia, the assessment of severity, and clinical standardization in the Pneumonia Etiology Research for Child Health study

To develop a case definition for the Pneumonia Etiology Research for Child Health (PERCH) project, we sought a widely acceptable classification that was linked to existing pneumonia research and focused on very severe cases. We began with the World Health Organization's classification of severe/very severe pneumonia and refined it through literature reviews and a 2-stage process of expert consultation. PERCH will study hospitalized children, aged 1-59 months, with pneumonia who present with cough or difficulty breathing and have either severe pneumonia (lower chest wall indrawing) or very severe pneumonia (central cyanosis, difficulty breastfeeding/drinking, vomiting everything, convulsions, lethargy, unconsciousness, or head nodding). It will exclude patients with recent hospitalization and children with wheeze whose indrawing resolves after bronchodilator therapy. The PERCH investigators agreed upon standard interpretations of the symptoms and signs. These will be maintained by a clinical standardization monitor who conducts repeated instruction at each site and by recurrent local training and testing.

Point-of-care measurement of blood lactate in children admitted with febrile illness to an African District Hospital

BACKGROUND

Lactic acidosis is a consistent predictor of mortality owing to severe infectious disease, but its detection in low-income settings is limited to the clinical sign of "deep breathing" because of the lack of accessible technology for its measurement. We evaluated the use of a point-of-care (POC) diagnostic device for blood lactate measurement to assess the severity of illness in children admitted to a district hospital in Tanzania.

METHODS

Children between the ages of 2 months and 13 years with a history of fever were enrolled in the study during a period of 1 year. A full clinical history and examination were undertaken, and blood was collected for culture, microscopy, complete blood cell count, and POC measurement of blood lactate and glucose.

RESULTS

The study included 3248 children, of whom 164 (5.0%) died; 45 (27.4%) of these had raised levels of blood lactate (>5 mmol/L) but no deep breathing. Compared with mortality in children with lactate levels of ≤ 3 mmol/L, the unadjusted odds of dying were 1.6 (95% confidence interval [CI].8-3.0), 3.4 (95% CI, 1.5-7.5), and 8.9 (95% CI, 4.7-16.8) in children with blood lactate levels of 3.1-5.0, 5.1-8.0, or >8.0 mmol/L, respectively. The prevalence of raised lactate levels (>5 mmol/L) was greater in children with malaria than in children with nonmalarial febrile illness (P < .001) although the associated mortality was greater in slide-negative children.

CONCLUSIONS

POC lactate measurement can contribute to the assessment of children admitted to hospital with febrile illness and can also create an opportunity for more hospitals in resource-poor settings to participate in clinical trials of interventions to reduce mortality associated with hyperlactatemia.

Clinical predictors of severe malarial anaemia in a holoendemic Plasmodium falciparum transmission area

Severe malarial anaemia (SMA) is a common complication of Plasmodium falciparum infections, resulting in mortality rates that may exceed 30% in paediatric populations residing in holoendemic transmission areas. One strategy for reducing the morbidity and mortality associated with SMA is to identify clinical predictors that can be readily recognized by caregivers for prompt therapeutic interventions. To determine clinical predictors of SMA, Kenyan children (3-36 months, n = 671) presenting with acute illness at a rural hospital in Siaya District were recruited. Demographic, clinical, laboratory and haematological parameters were measured upon enrolment. As human immunodeficiency virus-1 and bacteraemia promote reduced haemoglobin (Hb) concentrations, children with these infections were excluded from the analyses. Children with P. falciparum mono-infections (n = 355) were stratified into three groups: uncomplicated malaria (Hb >or= 110 g/l); non-SMA (60 Collapse

Key Words Collapse

MESH Headings

• Anemia/diagnosis
• Anemia/genetics
• Anemia/parasitology
• Child, Preschool
• Endemic Diseases
• Female
• Humans
• Infant
• Kenya/epidemiology
• Malaria, Falciparum/complications
• Malaria, Falciparum/epidemiology
• Malaria, Falciparum/genetics
• Malaria, Falciparum/transmission
• Male
• Pallor/parasitology
• Physical Examination/methods
• Platelet Count
• Reticulocyte Count
• Risk Factors

Collapse

Grants

• D43 TW005884 FIC NIH HHS
• R01 AI051305 NIAID NIH HHS
• R01 AI051305-09 NIAID NIH HHS
• T32 AI007538 NIAID NIH HHS

Collapse

Affiliation(s)

Enrico M Novelli Division of Haematology/Oncology, Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
James B Hittner
Gregory C Davenport
Collins Ouma
Tom Were
Stephen Obaro
Sandra Kaplan
John M Ong'echa
Douglas J Perkins

Collapse

Community-based validation of assessment of newborn illnesses by trained community health workers in Sylhet district of Bangladesh

OBJECTIVES

To validate trained community health workers' recognition of signs and symptoms of newborn illnesses and classification of illnesses using a clinical algorithm during routine home visits in rural Bangladesh.

METHODS

Between August 2005 and May 2006, 288 newborns were assessed independently by a community health worker and a study physician. Based on a 20-sign algorithm, sick neonates were classified as having very severe disease, possible very severe disease or no disease. The physician's assessment was considered as the gold standard.

RESULTS

Community health workers correctly classified very severe disease in newborns with a sensitivity of 91%, specificity of 95% and kappa value of 0.85 (P < 0.001). Community health workers' recognition showed a sensitivity of more than 60% and a specificity of 97-100% for almost all signs and symptoms.

CONCLUSION

Community health workers with minimal training can use a diagnostic algorithm to identify severely ill newborns with high validity.

Validation of community health workers' assessment of neonatal illness in rural Bangladesh

OBJECTIVE

To estimate the validity (sensitivity, specificity, and positive and negative predictive values) of a clinical algorithm as used by community health workers (CHWs) to detect and classify neonatal illness during routine household visits in rural Bangladesh.

METHODS

CHWs evaluated breastfeeding and symptoms and signs of illness in 395 neonates selected randomly from neonatal illness surveillance during household visits on postnatal days 0, 2, 5 and 8. Neonates classified with very severe disease (VSD) were referred to a community-based hospital. Within 12 hours of CHW assessments, physicians independently evaluated all neonates seen in a given day by one CHW, randomly chosen from among 36 project CHWs. Physicians recorded symptoms and signs of illness, classified the illness, and determined whether the newborn needed referral-level care at the hospital. Physicians' identification and classification were used as the gold standard in determining the validity of CHWs' identification of symptoms and signs of illness and its classification.

FINDINGS

CHWs' classification of VSD showed a sensitivity of 73%, a specificity of 98%, a positive predictive value of 57% and a negative predictive value of 99%. A maternal report of any feeding problem as ascertained by physician questioning was significantly associated (P < 0.001) with 'not sucking at all' and 'not attached at all' or 'not well attached' as determined clinically by CHWs during feeding assessment.

CONCLUSION

CHWs identified with high validity the neonates with severe illness needing referral-level care. Home-based illness recognition and management, including referral of neonates with severe illness by CHWs, is a promising strategy for improving neonatal health and survival in low-resource developing country settings.

Age patterns of severe paediatric malaria and their relationship to Plasmodium falciparum transmission intensity

Background

The understanding of the epidemiology of severe malaria in African children remains incomplete across the spectrum of Plasmodium falciparum transmission intensities through which communities might expect to transition, as intervention coverage expands.

Methods

Paediatric admission data were assembled from 13 hospitals serving 17 communities between 1990 and 2007. Estimates of Plasmodium falciparum transmission intensity in these communities were assembled to be spatially and temporally congruent to the clinical admission data. The analysis focused on the relationships between community derived parasite prevalence and the age and clinical presentation of paediatric malaria in children aged 0–9 years admitted to hospital.

Results

As transmission intensity declined a greater proportion of malaria admissions were in older children. There was a strong linear relationship between increasing transmission intensity and the proportion of paediatric malaria admissions that were infants (R² = 0.73, p < 0.001). Cerebral malaria was reported among 4% and severe malaria anaemia among 17% of all malaria admissions. At higher transmission intensity cerebral malaria was a less common presentation compared to lower transmission sites. There was no obvious relationship between the proportions of children with severe malaria anaemia and transmission intensity.

Conclusion

As the intensity of malaria transmission declines in Africa through the scaling up of insecticide-treated nets and other vector control measures a focus of disease prevention among very young children becomes less appropriate. The understanding of the relationship between parasite exposure and patterns of disease risk should be used to adapt malaria control strategies in different epidemiological settings.

Inter-observer variation in paediatric clinical signs between different grades of staff examining children admitted to hospital in Tanzania

BACKGROUND AND OBJECTIVE

Children are often admitted to district hospitals in Africa without an adequate record of clinical examination, a problem that could be reduced by greater involvement of nurses in their assessment. We aimed to ascertain whether hospital nurses in a district hospital could conduct paediatric examinations as reliably as clinical staff, when provided with a short structured training session.

METHODS

Hospital nurses (HN), hospital clinical officers (HCO) and research clinical officers (RCO) repeated examinations on children admitted to the paediatric ward shortly after the first examination by an RCO. Kappa scores were used to compare the agreement on the presence or absence of basic clinical signs by different categories of staff.

RESULTS

Among 439 paired examinations the agreement between RCOs on clinical signs was slightly higher than for HCOs or HNs; the mean (median) Kappa scores for all signs examined were 0.54 (0.57) for RCO-RCO, 0.49 (0.49) for RCO-HCO and 0.50 (0.49) for RCO-HN. Levels of agreement were lower if children were under the age of 18 months or if they cried during the examination.

CONCLUSIONS

Nurses with basic training appear to perform as well as clinically trained staff in eliciting essential signs in acutely ill children. Their role in the initial and ongoing assessment of these children should be reviewed in light of the critical shortages in clinically trained staff in African hospitals.

Lactic Acidosis in Gabonese Children with Severe Malaria Is Unrelated to Dehydration

BACKGROUND

Hyperlactatemia is an important and common complication of severe malaria. We investigated changes in fluid compartment volumes in patients with severe malaria and control patients with the use of bioimpedence analysis.

METHODS

We estimated extracellular water and total body water volumes in a total of 180 children: 56 with severe malaria, 94 with moderate malaria, 24 with respiratory tract infection, and 6 with severe diarrhea.

RESULTS

There was a mean (+/-SD) decrease in total body water volume of 17+/-24 mL/kg (or 3% of total body water volume) in patients with severe malaria. This compares with a mean (+/-SD) decrease in total body water volume of 33+/-28 mL/kg (or 6% of total body water volume) in patients with severe diarrhea. There was no increase in extracellular water volume in patients with severe malaria, suggesting no significant intravascular volume depletion in patients with severe malaria. There was no relationship between lactatemia and any changes in fluid compartment volumes.

CONCLUSIONS

The changes in fluid volumes that were observed are unlikely to be of physiological significance in the pathophysiology of severe malaria.

The interrater reliability of a validated bronchiolitis severity assessment tool

BACKGROUND

We previously constructed and tested a bronchiolitis severity assessment tool in 2 independent hospitals. The model uses age, work of breathing, dehydration and tachycardia to successfully predict disease severity.

OBJECTIVE

To prospectively measure the interrater reliability of a bronchiolitis severity assessment tool and of its component variables.

DESIGN

Prospective observational survey.

SETTING

A county teaching hospital emergency department serving a mixed urban and rural population with an emergency medicine residency program in 2-3-4 format.

SUBJECTS

Thirty-two physicians evaluated a convenience sample of children aged less than 18 months presenting to the emergency department with a clinical diagnosis of bronchiolitis during a single season.

METHODS

Two physicians independently examined each patient. Each physician completed a physical examination template that included the variables used in the severity assessment tool. Interrater agreement was measured for the variables work of breathing and dehydration and for the tool as a whole using a weighted kappa statistic.

RESULTS

One hundred and forty-six cases were enrolled. Twenty-five were dropped for incomplete data collection. The actual weighted agreement on overall classification was 92%; expected, 73%, kappa = 0.676; P < 0.0001. The actual weighted agreement for dehydration was at 95%; expected, 92%, kappa = 0.305; P = 0.0001. The agreement for work of breathing was 95%; expected, 86%; kappa = 0.611; P < 0.0001. The overall model showed better interrater reliability than its individual components.

CONCLUSIONS

Overall interrater reliability for this bronchiolitis severity assessment tool is substantial.

Development of clinical sign based algorithms for community based assessment of omphalitis

BACKGROUND

In developing countries, newborn omphalitis contributes significantly to morbidity and mortality. Community based identification and management of omphalitis will require standardised clinical sign based definitions.

OBJECTIVE

To identify optimal sign based algorithms to define omphalitis in the community and to evaluate the reliability and validity of cord assessments by non-specialist health workers for clinical signs of omphalitis.

DESIGN

Within a trial of the impact of topical antiseptics on umbilical cord infection in rural Nepal, digital images of the umbilical cord were collected. Workers responsible for in-home examinations of the umbilical cord evaluated the images for signs of infection (pus, redness, swelling). Intraworker and interworker agreement was evaluated, and sensitivity and specificity compared with a physician generated gold standard ranking were estimated.

RESULTS

Sensitivity and specificity of worker evaluations were high for pus (90% and 96% respectively) and moderate for redness (57% and 95% respectively). Swelling was the least reliably identified sign. Measures of observer agreement were similar to that previously recorded between experts evaluating subjective skin conditions. A composite definition for omphalitis that combined pus and redness without regard to swelling was the most sensitive and specific.

CONCLUSIONS

Two sign based algorithms for defining omphalitis are recommended for use in the community. Focusing on redness extending to the skin around the base of the stump will identify cases of moderate and high severity. Requiring both the presence of pus and redness will result in a definition with very high specificity and moderate to high sensitivity.

Effect of handwashing on child health: a randomised controlled trial

BACKGROUND

More than 3.5 million children aged less than 5 years die from diarrhoea and acute lower respiratory-tract infection every year. We undertook a randomised controlled trial to assess the effect of handwashing promotion with soap on the incidence of acute respiratory infection, impetigo, and diarrhoea.

METHODS

In adjoining squatter settlements in Karachi, Pakistan, we randomly assigned 25 neighbourhoods to handwashing promotion; 11 neighbourhoods (306 households) were randomised as controls. In neighbourhoods with handwashing promotion, 300 households each were assigned to antibacterial soap containing 1.2% triclocarban and to plain soap. Fieldworkers visited households weekly for 1 year to encourage handwashing by residents in soap households and to record symptoms in all households. Primary study outcomes were diarrhoea, impetigo, and acute respiratory-tract infections (ie, the number of new episodes of illness per person-weeks at risk). Pneumonia was defined according to the WHO clinical case definition. Analysis was by intention to treat.

FINDINGS

Children younger than 5 years in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than controls (95% CI (-65% to -34%). Also compared with controls, children younger than 15 years in households with plain soap had a 53% lower incidence of diarrhoea (-65% to -41%) and a 34% lower incidence of impetigo (-52% to -16%). Incidence of disease did not differ significantly between households given plain soap compared with those given antibacterial soap.

INTERPRETATION

Handwashing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally-namely, diarrhoea and acute lower respiratory infections. Handwashing with daily bathing also prevents impetigo.

Validação e reprodutibilidade de sinais clínicos no diagnóstico de anemia em crianças

Este trabalho teve como objetivo avaliar a validade e reprodutibilidade dos sinais clínicos (palidez palmar e conjuntival) no diagnóstico de anemia em crianças de 6-23 meses, no Nordeste do Brasil, por meio de estudo transversal com amostra de 421 crianças, realizado nos ambulatórios de pediatria e puericultura do Instituto Materno Infantil de Pernambuco. Os sinais clínicos foram avaliados por dois examinadores. A reprodutibilidade foi avaliada pelo coeficiente de kappa e a validação (sensibilidade e especificidade) foi realizada utilizando-se a hemoglobina como padrão. Os sinais clínicos demonstraram baixa reprodutibilidade (kappa de 0,24-0,25). A maior sensibilidade para diagnosticar anemia (Hb < 11g/dl) e anemia moderada/ grave (Hb < 9g/dl), respectivamente, foi apresentada pela combinação de palidez palmar ou conjuntival (39,7% e 53,5%), seguida pela palidez palmar isoladamente (29,9% e 40,0%). A maior especificidade foi para a palidez palmar comparada à palma da mão da mãe (95,5% e 90,1% para Hb < 11g/dl e Hb < 9g/dl, respectivamente). A sensibilidade dos sinais clínicos foi melhor para diagnosticar a anemia moderada/grave, especialmente quando a palidez palmar e conjuntival são combinadas, sugerindo que a utilização dos mesmos não se constitui em um bom instrumento para diagnosticar anemia leve.