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Hill J. Implementation of post-discharge malaria chemoprevention (PDMC) in Benin, Kenya, Malawi, and Uganda: stakeholder engagement meeting report. Malar J 2024; 23:89. [PMID: 38539181 PMCID: PMC10976733 DOI: 10.1186/s12936-023-04810-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/29/2023] [Indexed: 04/01/2024] Open
Abstract
A Stakeholder engagement meeting on the implementation of post-discharge malaria chemoprevention (PDMC) in Benin, Kenya, Malawi, and Uganda was held in Nairobi, Kenya, on 27 September 2023. Representatives from the respective National Malaria Control Programmes, the World Health Organization (WHO) Geneva, Africa Regional and Kenya offices, research partners, non-governmental organizations, and the Medicines for Malaria Venture participated. PDMC was recommended by the WHO in June 2022 and involves provision of a full anti-malarial treatment course at regular intervals during the post-discharge period in children hospitalized with severe anaemia in areas of moderate-to-high malaria transmission. The WHO recommendation followed evidence from a meta-analysis of three clinical trials and from acceptability, delivery, cost-effectiveness, and modelling studies. The trials were conducted in The Gambia using monthly sulfadoxine-pyrimethamine during the transmission season, in Malawi using monthly artemether-lumefantrine, and in Kenya and Uganda using monthly dihydroartemisinin-piperaquine, showing a significant reduction in all-cause mortality by 77% (95% CI 30-98) and a 55% (95% CI 44-64) reduction in all-cause hospital readmissions 6 months post-discharge. The recommendation has not yet been implemented in sub-Saharan Africa. There is no established platform for PDMC delivery. The objectives of the meeting were for the participating countries to share country contexts, plans and experiences regarding the adoption and implementation of PDMC and to explore potential delivery platforms in each setting. The meeting served as the beginning of stakeholder engagement within the PDMC Saves Lives project and will be followed by formative and implementation research to evaluate alternative delivery strategies in selected countries. Meeting highlights included country consensus on use of dihydroartemisinin-piperaquine for PDMC and expansion of the target group to "severe anaemia or severe malaria", in addition to identifying country-specific options for PDMC delivery for evaluation in implementation research. Further exploration is needed on whether the age group should be extended to school-age children.
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Affiliation(s)
- Jenny Hill
- Institut de Recherche Clinique du Benin (IRCB), Cotonou, Benin.
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Apaza C, Cuna W, Brañez F, Passera R, Rodriguez C. Frequency of Gastrointestinal Parasites, Anemia, and Nutritional Status among Children from Different Geographical Regions of Bolivia. J Trop Med 2023; 2023:5020490. [PMID: 38107388 PMCID: PMC10725312 DOI: 10.1155/2023/5020490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 12/19/2023] Open
Abstract
The study aimed to measure the frequency of occurrence of infections with helminths, protozoa, and risk factors of undernutrition and anemia among schoolchildren from the Bolivian highland (altiplano) and lowland (subtropical) rural regions, with a high frequency of gastrointestinal parasite infections. Cross-sectional data were collected from 790 children, 5-13 years old. Microscopic examination of stool using the Ritchie technique, hemoglobin testing using the HemoCue analyzer, and anthropometric measurements were performed. Over 60% and 20% of children were infected with protozoa and helminth parasites, respectively. Infections caused by pathogenic Hymenolepis nana (15.7-5.2%), Ascaris lumbricoides (41.9-28.5%), Giardia lamblia (30.1-11.2%), Entamoeba histolytica (5.7-0.7%), and nonpathogenic Entamoeba coli (48.9-16%), Blastocystis hominis (40.2-28.5%), Iodamoeba butschli (16.1-2.5%), Chilomastix mesnili (19.2-7.3%), and Entamoeba histolytica/dispar (7.4-5.5%) parasites, were more prevalent in the highlands than the lowlands. Single parasitic infections were more prevalent in the lowlands; polyparasitism of light or heavy intensity predominated in the highlands. A strongly increased risk of anemia and a low prevalence of wasting were determined in children in the highlands. A higher risk for stunting was associated with children of older age, and a low burden of intestinal helminths would prevent wasting in children of highlands. Infections with A. lumbricoides and G. lamblia pathogens in older children were not significant covariates for stunting. Environmental, nutritional, and parasitic factors may predispose to anemia in the highlands. A nutritional intervention and parasite control effort will substantially improve children´s health in the highlands.
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Affiliation(s)
- Ceilan Apaza
- Hospital Municipal de Chulumani, Chulumani, La Paz, Bolivia
| | - Washington Cuna
- Unidad de Inmunología Parasitaria, Facultad de Medicina, Universidad Mayor de San Andrés, La Paz, Bolivia
| | - Froilán Brañez
- Unidad de Laboratorio Clínico, Hospital de Caranavi, Caranavi, La Paz, Bolivia
| | - Roberto Passera
- University of Turin, Department of Medical Science, Division of Nuclear Medicine, Corso AM Digliotti 14, Turin 10126, Italy
| | - Celeste Rodriguez
- Unidad de Inmunología Parasitaria, Facultad de Medicina, Universidad Mayor de San Andrés, La Paz, Bolivia
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Kwambai TK, Kariuki S, Smit MR, Nevitt S, Onyango E, Oneko M, Khagayi S, Samuels AM, Hamel MJ, Laserson K, Desai M, ter Kuile FO. Post-Discharge Risk of Mortality in Children under 5 Years of Age in Western Kenya: A Retrospective Cohort Study. Am J Trop Med Hyg 2023; 109:704-712. [PMID: 37549893 PMCID: PMC10484264 DOI: 10.4269/ajtmh.23-0186] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/26/2023] [Indexed: 08/09/2023] Open
Abstract
Limited evidence suggests that children in sub-Saharan Africa hospitalized with all-cause severe anemia or severe acute malnutrition (SAM) are at high risk of dying in the first few months after discharge. We aimed to compare the risks of post-discharge mortality by health condition among hospitalized children in an area with high malaria transmission in western Kenya. We conducted a retrospective cohort study among recently discharged children aged < 5 years using mortality data from a health and demographic surveillance system that included household and pediatric in-hospital surveillance. Cox regression was used to compare post-discharge mortality. Between 2008 and 2013, overall in-hospital mortality was 2.8% (101/3,639). The mortality by 6 months after discharge (primary outcome) was 6.2% (159/2,556) and was highest in children with SAM (21.6%), followed by severe anemia (15.5%), severe pneumonia (5.6%), "other conditions" (5.6%), and severe malaria (0.7%). Overall, the 6-month post-discharge mortality in children hospitalized with SAM (hazard ratio [HR] = 3.95, 2.60-6.00, P < 0.001) or severe anemia (HR = 2.55, 1.74-3.71, P < 0.001) was significantly higher than that in children without these conditions. Severe malaria was associated with lower 6-month post-discharge mortality than children without severe malaria (HR = 0.33, 0.21-0.53, P < 0.001). The odds of dying by 6 months after discharge tended to be higher than during the in-hospital period for all children, except for those admitted with severe malaria. The first 6 months after discharge is a high-risk period for mortality among children admitted with severe anemia and SAM in western Kenya. Strategies to address this risk period are urgently needed.
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Affiliation(s)
- Titus K. Kwambai
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Simon Kariuki
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Menno R. Smit
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Amsterdam Centre for Global Child Health, Emma Children’s Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Sarah Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Eric Onyango
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Martina Oneko
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Sammy Khagayi
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Aaron M. Samuels
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary J. Hamel
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kayla Laserson
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meghna Desai
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Feiko O. ter Kuile
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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John CC, Hamer DH. Post-Discharge Mortality in Recently Hospitalized African Children: A Hidden Crisis. Am J Trop Med Hyg 2023; 109:495-496. [PMID: 37640287 PMCID: PMC10484279 DOI: 10.4269/ajtmh.23-0525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Affiliation(s)
- Chandy C. John
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Mburu W, Conroy AL, Cusick SE, Bangirana P, Bond C, Zhao Y, Opoka RO, John CC. The Impact of Undernutrition on Cognition in Children with Severe Malaria and Community Children: A Prospective 2-Year Cohort Study. J Trop Pediatr 2021; 67:6424536. [PMID: 34755192 PMCID: PMC8578678 DOI: 10.1093/tropej/fmab091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The frequency of recovery from undernutrition after an episode of severe malaria, and the relationship between undernutrition during severe malaria and clinical and cognitive outcomes are not well characterized. METHODS We evaluated undernutrition and cognition in children in Kampala, Uganda 18 months to 5 years of age with cerebral malaria (CM), severe malarial anemia (SMA) or community children (CC). The Mullen Scales of Early Learning was used to measure cognition. Undernutrition, defined as 2 SDs below median for weight-for-age (underweight), height-for-age (stunting) or weight-for-height (wasting), was compared with mortality, hospital readmission and cognition over 24-month follow-up. RESULTS At enrollment, wasting was more common in CM (16.7%) or SMA (15.9%) than CC (4.7%) (both p < 0.0001), and being underweight was more common in SMA (27.0%) than CC (12.8%; p = 0.001), while prevalence of stunting was similar in all three groups. By 6-month follow-up, prevalence of wasting or being underweight did not differ significantly between children with severe malaria and CC. Undernutrition at enrollment was not associated with mortality or hospital readmission, but children who were underweight or stunted at baseline had lower cognitive z-scores than those who were not {underweight, mean difference [95% confidence interval (CI)] -0.98 (-1.66, -0.31), -0.72 (-1.16, -0.27) and -0.61 (-1.08, -0.13); and stunted, -0.70 (-1.25, -0.15), -0.73 (-1.16, -0.31) and -0.61 (-0.96, -0.27), for CM, SMA and CC, respectively}. CONCLUSION In children with severe malaria, wasting and being underweight return to population levels after treatment. However, being stunted or underweight at enrollment was associated with worse long-term cognition in both CC and children with severe malaria.
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Affiliation(s)
- Waruiru Mburu
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55454, USA,Correspondence: Waruiru Mburu, Division of Epidemiology and Community Health, University of Minnesota, 1300 S 2nd St, Unit 300, Minneapolis, MN 55454, USA. Tel: 612-624-6368. E-mail: <> and Chandy C. John, Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, 1044 W Walnut Street, R4 402D, Indianapolis, IN 46202, USA. Tel: 317-274-8940. E-mail: <>
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Sarah E Cusick
- Division of Global Pediatrics, Department of Pediatrics, and Center for Neurobehavioral Development, University of Minnesota, Minneapolis, MN 55455, USA
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Caitlin Bond
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yi Zhao
- Department of Biostatistics, Fairbanks School of Public Health, Indiana University—Purdue University at Indianapolis, Indianapolis, IN 46202, USA
| | - Robert O Opoka
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Chandy C John
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA,Department of Biostatistics, Fairbanks School of Public Health, Indiana University—Purdue University at Indianapolis, Indianapolis, IN 46202, USA,Correspondence: Waruiru Mburu, Division of Epidemiology and Community Health, University of Minnesota, 1300 S 2nd St, Unit 300, Minneapolis, MN 55454, USA. Tel: 612-624-6368. E-mail: <> and Chandy C. John, Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, 1044 W Walnut Street, R4 402D, Indianapolis, IN 46202, USA. Tel: 317-274-8940. E-mail: <>
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Conroy AL, Opoka RO, Bangirana P, Namazzi R, Okullo AE, Georgieff MK, Cusick S, Idro R, Ssenkusu JM, John CC. Parenteral artemisinins are associated with reduced mortality and neurologic deficits and improved long-term behavioral outcomes in children with severe malaria. BMC Med 2021; 19:168. [PMID: 34315456 PMCID: PMC8317420 DOI: 10.1186/s12916-021-02033-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/11/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In 2011, the World Health Organization recommended injectable artesunate as the first-line therapy for severe malaria (SM) due to its superiority in reducing mortality compared to quinine. There are limited data on long-term clinical and neurobehavioral outcomes after artemisinin use for treatment of SM. METHODS From 2008 to 2013, 502 Ugandan children with two common forms of SM, cerebral malaria and severe malarial anemia, were enrolled in a prospective observational study assessing long-term neurobehavioral and cognitive outcomes following SM. Children were evaluated a week after hospital discharge, and 6, 12, and 24 months of follow-up, and returned to hospital for any illness. In this study, we evaluated the impact of artemisinin derivatives on survival, post-discharge hospital readmission or death, and neurocognitive and behavioral outcomes over 2 years of follow-up. RESULTS 346 children received quinine and 156 received parenteral artemisinin therapy (artemether or artesunate). After adjustment for disease severity, artemisinin derivatives were associated with a 78% reduction in in-hospital mortality (adjusted odds ratio, 0.22; 95% CI, 0.07-0.67). Among cerebral malaria survivors, children treated with artemisinin derivatives also had reduced neurologic deficits at discharge (quinine, 41.7%; artemisinin derivatives, 23.7%, p=0.007). Over a 2-year follow-up, artemisinin derivatives as compared to quinine were associated with better adjusted scores (negative scores better) in internalizing behavior and executive function in children irrespective of the age at severe malaria episode. After adjusting for multiple comparisons, artemisinin derivatives were associated with better adjusted scores in behavior and executive function in children <6 years of age at severe malaria exposure following adjustment for child age, sex, socioeconomic status, enrichment in the home environment, and the incidence of hospitalizations over follow-up. Children receiving artesunate had the greatest reduction in mortality and benefit in behavioral outcomes and had reduced inflammation at 1-month follow-up compared to children treated with quinine. CONCLUSIONS Treatment of severe malaria with artemisinin derivatives, particularly artesunate, results in reduced in-hospital mortality and neurologic deficits in children of all ages, reduced inflammation following recovery, and better long-term behavioral outcomes. These findings suggest artesunate has long-term beneficial effects in children surviving severe malaria.
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Affiliation(s)
- Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4 402C 1044 West Walnut St, Indianapolis, IN, 46202, USA.
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Allen E Okullo
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Sarah Cusick
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4 402C 1044 West Walnut St, Indianapolis, IN, 46202, USA.,Division of Global Pediatrics, University of Minnesota Medical School, Minneapolis, USA
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Batte A, Berrens Z, Murphy K, Mufumba I, Sarangam ML, Hawkes MT, Conroy AL. Malaria-Associated Acute Kidney Injury in African Children: Prevalence, Pathophysiology, Impact, and Management Challenges. Int J Nephrol Renovasc Dis 2021; 14:235-253. [PMID: 34267538 PMCID: PMC8276826 DOI: 10.2147/ijnrd.s239157] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/26/2021] [Indexed: 01/02/2023] Open
Abstract
Acute kidney injury (AKI) is emerging as a complication of increasing clinical importance associated with substantial morbidity and mortality in African children with severe malaria. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI, an estimated 24–59% of African children with severe malaria have AKI with most AKI community-acquired. AKI is a risk factor for mortality in pediatric severe malaria with a stepwise increase in mortality across AKI stages. AKI is also a risk factor for post-discharge mortality and is associated with increased long-term risk of neurocognitive impairment and behavioral problems in survivors. Following injury, the kidney undergoes a process of recovery and repair. AKI is an established risk factor for chronic kidney disease and hypertension in survivors and is associated with an increased risk of chronic kidney disease in severe malaria survivors. The magnitude of the risk and contribution of malaria-associated AKI to chronic kidney disease in malaria-endemic areas remains undetermined. Pathways associated with AKI pathogenesis in the context of pediatric severe malaria are not well understood, but there is emerging evidence that immune activation, endothelial dysfunction, and hemolysis-mediated oxidative stress all directly contribute to kidney injury. In this review, we outline the KDIGO bundle of care and highlight how this could be applied in the context of severe malaria to improve kidney perfusion, reduce AKI progression, and improve survival. With increased recognition that AKI in severe malaria is associated with substantial post-discharge morbidity and long-term risk of chronic kidney disease, there is a need to increase AKI recognition through enhanced access to creatinine-based and next-generation biomarker diagnostics. Long-term studies to assess severe malaria-associated AKI’s impact on long-term health in malaria-endemic areas are urgently needed.
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Affiliation(s)
- Anthony Batte
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Zachary Berrens
- Department of Pediatrics, Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristin Murphy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ivan Mufumba
- CHILD Research Laboratory, Global Health Uganda, Kampala, Uganda
| | | | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Ngari MM, Obiero C, Mwangome MK, Nyaguara A, Mturi N, Murunga S, Otiende M, Iversen PO, Fegan GW, Walson JL, Berkley JA. Mortality during and following hospital admission among school-aged children: a cohort study. Wellcome Open Res 2021; 5:234. [PMID: 33195820 PMCID: PMC7656274 DOI: 10.12688/wellcomeopenres.16323.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya. Methods: A retrospective cohort study of children 5−12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality. Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74−116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admission. Comorbidities included 623 (16%) with severe wasting, 386 (10%) with severe stunting, 90 (2.3%) with oedematous malnutrition and 194 (5.0%) with HIV infection. 132 (3.4%) children died during hospitalisation. Inpatient death was associated with signs of disease severity, age, bacteraemia, HIV infection and severe stunting. After discharge, 89/2,997 (3.0%) children died within one year during 2,853 child-years observed (31.2 deaths [95%CI, 25.3−38.4] per 1,000 child-years). 63/89 (71%) of post-discharge deaths occurred within three months and 45% of deaths occurred outside hospital. Post-discharge mortality was positively associated with weak pulse, tachypnoea, severe anaemia, HIV infection and severe wasting and negatively associated with malaria. Conclusions: Reasons for admissions are markedly different from those reported in under-fives. There was significant post-discharge mortality, suggesting hospitalisation is a marker of risk in this population. Our findings inform guideline development to include risk stratification, targeted post-discharge care and facilitate access to healthcare to improve survival in the early months post-discharge in school-aged children.
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Affiliation(s)
- Moses M Ngari
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Christina Obiero
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Martha K Mwangome
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Amek Nyaguara
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Sheila Murunga
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Mark Otiende
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Per Ole Iversen
- Department of Nutrition, IBM, University of Oslo, Oslo, Norway.,Department of Haematology, Oslo University Hospital, Oslo, Norway.,Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa
| | - Gregory W Fegan
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya.,Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.,Departments of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.,Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
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Ngari MM, Obiero C, Mwangome MK, Nyaguara A, Mturi N, Murunga S, Otiende M, Iversen PO, Fegan GW, Walson JL, Berkley JA. Mortality during and following hospital admission among school-aged children: a cohort study. Wellcome Open Res 2021; 5:234. [PMID: 33195820 PMCID: PMC7656274 DOI: 10.12688/wellcomeopenres.16323.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 11/03/2023] Open
Abstract
Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya. Methods: A retrospective cohort study of children 5-12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality. Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74-116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admission. Comorbidities included 623 (16%) with severe wasting, 386 (10%) with severe stunting, 90 (2.3%) with oedematous malnutrition and 194 (5.0%) with HIV infection. 132 (3.4%) children died during hospitalisation. Inpatient death was associated with signs of disease severity, age, bacteraemia, HIV infection and severe stunting. After discharge, 89/2,997 (3.0%) children died within one year during 2,853 child-years observed (31.2 deaths [95%CI, 25.3-38.4] per 1,000 child-years). 63/89 (71%) of post-discharge deaths occurred within three months and 45% of deaths occurred outside hospital. Post-discharge mortality was positively associated with weak pulse, tachypnoea, severe anaemia, HIV infection and severe wasting and negatively associated with malaria. Conclusions: Reasons for admissions are markedly different from those reported in under-fives. There was significant post-discharge mortality, suggesting hospitalisation is a marker of risk in this population. Our findings inform guideline development to include risk stratification, targeted post-discharge care and facilitate access to healthcare to improve survival in the early months post-discharge in school-aged children.
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Affiliation(s)
- Moses M Ngari
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Christina Obiero
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Martha K Mwangome
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Amek Nyaguara
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Sheila Murunga
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Mark Otiende
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Per Ole Iversen
- Department of Nutrition, IBM, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa
| | - Gregory W Fegan
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- Departments of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
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10
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Opoka RO, Waiswa A, Harriet N, John CC, Tumwine JK, Karamagi C. Blackwater Fever in Ugandan Children With Severe Anemia is Associated With Poor Postdischarge Outcomes: A Prospective Cohort Study. Clin Infect Dis 2020; 70:2247-2254. [PMID: 31300826 PMCID: PMC7245149 DOI: 10.1093/cid/ciz648] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/11/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Blackwater fever (BWF), one of the complications of severe malaria, has recently re-emerged as a cause of severe anemia (SA) in African children. However, postdischarge morbidity in children with BWF has previously not been described. METHODS This was a descriptive cohort study in which children, aged 0-5 years, admitted to Jinja Regional Referral Hospital with acute episodes of SA (hemoglobin ≤5.0 g/dL) were followed up for 6 months after hospitalization. Incidence of readmissions or deaths during the follow-up period was compared between SA children with BWF and those without BWF. RESULTS A total of 279 children with SA including those with BWF (n = 92) and no BWF (n = 187) were followed for the duration of the study. Overall, 128 (45.9%) of the study participants were readmitted at least once while 22 (7.9%) died during the follow-up period. After adjusting for age, sex, nutritional status, and parasitemia, SA children with BWF had higher risk of readmissions (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.1-2.5) and a greater risk of death (HR. 3.37; 95% CI, 1.3-8.5) compared with those without BWF. Malaria and recurrence of SA were the most common reasons for readmissions. CONCLUSIONS There is a high rate of readmissions and deaths in the immediate 6 months after initial hospitalization among SA children in the Jinja hospital. SA children with BWF had increased risk of readmissions and deaths in the postdischarge period. Postdischarge malaria chemoprophylaxis should be considered for SA children living in malaria endemic areas.
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Affiliation(s)
- Robert O Opoka
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala
| | - Ali Waiswa
- Global Health Uganda (GHU) Research Collaboration, Kampala
| | - Nambuya Harriet
- Nalufenya Children’s Ward, Jinja Regional Referral Hospital, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis
| | - James K Tumwine
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala
| | - Charles Karamagi
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala
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11
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Cusick SE, Opoka RO, Ssemata AS, Georgieff MK, John CC. Delayed iron improves iron status without altering malaria risk in severe malarial anemia. Am J Clin Nutr 2020; 111:1059-1067. [PMID: 32005992 PMCID: PMC7198296 DOI: 10.1093/ajcn/nqaa004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND WHO guidelines recommend concurrent iron and antimalarial treatment in children with malaria and iron deficiency, but iron may not be well absorbed or utilized during a malaria episode. OBJECTIVES We aimed to determine whether starting iron 28 d after antimalarial treatment in children with severe malaria and iron deficiency would improve iron status and lower malaria risk. METHODS We conducted a randomized clinical trial on the effect of immediate compared with delayed iron treatment in Ugandan children 18 mo-5 y of age with 2 forms of severe malaria: cerebral malaria (CM; n = 79) or severe malarial anemia (SMA; n = 77). Asymptomatic community children (CC; n = 83) were enrolled as a comparison group. Children with iron deficiency, defined as zinc protoporphyrin (ZPP) ≥ 80 µmol/mol heme, were randomly assigned to receive a 3-mo course of daily oral ferrous sulfate (2 mg · kg-1 · d-1) either concurrently with antimalarial treatment (immediate arm) or 28 d after receiving antimalarial treatment (delayed arm). Children were followed for 12 mo. RESULTS All children with CM or SMA, and 35 (42.2%) CC, were iron-deficient and were randomly assigned to immediate or delayed iron treatment. Immediate compared with delayed iron had no effect in any of the 3 study groups on the primary study outcomes (hemoglobin concentration and prevalence of ZPP ≥ 80 µmol/mol heme at 6 mo, malaria incidence over 12 mo). However, after 12 mo, children with SMA in the delayed compared with the immediate arm had a lower prevalence of iron deficiency defined by ZPP (29.4% compared with 65.6%, P = 0.006), a lower mean concentration of soluble transferrin receptor (6.1 compared with 7.8 mg/L, P = 0.03), and showed a trend toward fewer episodes of severe malaria (incidence rate ratio: 0.39; 95% CI: 0.14, 1.12). CONCLUSIONS In children with SMA, delayed iron treatment did not increase hemoglobin concentration, but did improve long-term iron status over 12 mo without affecting malaria incidence.This trial was registered at clinicaltrials.gov as NCT01093989.
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Affiliation(s)
- Sarah E Cusick
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew S Ssemata
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael K Georgieff
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Chandy C John
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN, USA
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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12
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Nallandhighal S, Park GS, Ho YY, Opoka RO, John CC, Tran TM. Whole-Blood Transcriptional Signatures Composed of Erythropoietic and NRF2-Regulated Genes Differ Between Cerebral Malaria and Severe Malarial Anemia. J Infect Dis 2019; 219:154-164. [PMID: 30060095 DOI: 10.1093/infdis/jiy468] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/24/2018] [Indexed: 02/03/2023] Open
Abstract
Background Among the severe malaria syndromes, severe malarial anemia (SMA) is the most common, whereas cerebral malaria (CM) is the most lethal. However, the mechanisms that lead to CM and SMA are unclear. Methods We compared transcriptomic profiles of whole blood obtained from Ugandan children with acute CM (n = 17) or SMA (n = 17) and community children without Plasmodium falciparum infection (n = 12) and determined the relationships among gene expression, hematological indices, and relevant plasma biomarkers. Results Both CM and SMA demonstrated predominantly upregulated enrichment of dendritic cell activation, inflammatory/Toll-like receptor/chemokines, and monocyte modules, but downregulated enrichment of lymphocyte modules. Nuclear factor, erythroid 2 like 2 (Nrf2)-regulated genes were overexpressed in children with SMA relative to CM, with the highest expression in children with both SMA and sickle cell disease (HbSS), corresponding with elevated plasma heme oxygenase-1 in this group. Erythroid and reticulocyte-specific signatures were markedly decreased in CM relative to SMA despite higher hemoglobin levels and appropriate increases in erythropoietin. Viral sensing/interferon-regulatory factor 2 module expression and plasma interferon-inducible protein-10/CXCL10 negatively correlated with reticulocyte-specific signatures. Conclusions Compared with SMA, CM is associated with downregulation of Nrf2-related and erythropoiesis signatures by whole-blood transcriptomics. Future studies are needed to confirm these findings and assess pathways that may be amenable to interventions to ameliorate CM and SMA.
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Affiliation(s)
- Srinivas Nallandhighal
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Gregory S Park
- Division of Global Pediatrics, Department of Pediatrics, University of Minnesota Medical School, Minneapolis
| | - Yen-Yi Ho
- Department of Statistics, College of Arts and Sciences, University of South Carolina, Columbia
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Chandy C John
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis.,Division of Global Pediatrics, Department of Pediatrics, University of Minnesota Medical School, Minneapolis.,Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis
| | - Tuan M Tran
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis.,Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis
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13
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Opoka RO, Ssemata AS, Oyang W, Nambuya H, John CC, Karamagi C, Tumwine JK. Adherence to clinical guidelines is associated with reduced inpatient mortality among children with severe anemia in Ugandan hospitals. PLoS One 2019; 14:e0210982. [PMID: 30682097 PMCID: PMC6347145 DOI: 10.1371/journal.pone.0210982] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In resource limited settings, there is variability in the level of adherence to clinical guidelines in the inpatient management of children with common conditions like severe anemia. However, there is limited data on the effect of adherence to clinical guidelines on inpatient mortality in children managed for severe anemia. METHODS We analyzed data from an uncontrolled before and after in-service training intervention to improve quality of care in Lira and Jinja regional referral hospitals in Uganda. Inpatient records of children aged 0 to 5 years managed as cases of 'severe anemia (SA)' were reviewed to ascertain adherence to clinical guidelines and compare inpatient deaths in SA children managed versus those not managed according to clinical guidelines. Logistic regression analysis was conducted to evaluate the relationship between clinical care factors and inpatient deaths amongst patients managed for SA. RESULTS A total of 1,131 children were assigned a clinical diagnosis of 'severe anemia' in the two hospitals. There was improvement in the level of care after the in-service training intervention with more children being managed according to clinical guidelines compared to the period before, 218/510 (42.7%) vs 158/621 (25.4%) (p < 0.001). Overall, children managed according to clinical guidelines had reduced risk of inpatient mortality compared to those not managed according to clinical guidelines, [OR 0.28, (95%, CI 0.14, 0.55), p = 0.001]. Clinical care factors associated with decreased risk of inpatient death included, having pre-transfusion hemoglobin done to confirm diagnosis [OR 0.5; 95% CI 0.29, 0.87], a co-morbid diagnosis of severe malaria [OR 0.4; 95% CI 0.25, 0.76], and being reviewed after admission by a clinician [OR 0.3; 95% CI 0.18, 0.59], while a co-morbid diagnosis of severe acute malnutrition was associated with increased risk of inpatient death [OR 4.2; 95% CI 2.15, 8.22]. CONCLUSION Children with suspected SA who are managed according to clinical guidelines have lower in-hospital mortality than those not managed according to the guidelines. Efforts to reduce inpatient mortality in SA children in resource-limited settings should focus on training and supporting health workers to adhere to clinical guidelines.
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Affiliation(s)
- Robert O. Opoka
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew S. Ssemata
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Oyang
- Children’s Ward, Lira Regional Referral Hospital, Lira, Uganda
| | - Harriet Nambuya
- Nalufenya Children’s Ward, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Charles Karamagi
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - James K. Tumwine
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
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14
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Nemetchek B, English L, Kissoon N, Ansermino JM, Moschovis PP, Kabakyenga J, Fowler-Kerry S, Kumbakumba E, Wiens MO. Paediatric postdischarge mortality in developing countries: a systematic review. BMJ Open 2018; 8:e023445. [PMID: 30593550 PMCID: PMC6318528 DOI: 10.1136/bmjopen-2018-023445] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To update the current evidence base on paediatric postdischarge mortality (PDM) in developing countries. Secondary objectives included an evaluation of risk factors, timing and location of PDM. DESIGN Systematic literature review without meta-analysis. DATA SOURCES Searches of Medline and EMBASE were conducted from October 2012 to July 2017. ELIGIBILITY CRITERIA Studies were included if they were conducted in developing countries and examined paediatric PDM. 1238 articles were screened, yielding 11 eligible studies. These were added to 13 studies identified in a previous systematic review including studies prior to October 2012. In total, 24 studies were included for analysis. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted and synthesised data using Microsoft Excel. RESULTS Studies were conducted mostly within African countries (19 of 24) and looked at all admissions or specific subsets of admissions. The primary subpopulations included malnutrition, respiratory infections, diarrhoeal diseases, malaria and anaemia. The anaemia and malaria subpopulations had the lowest PDM rates (typically 1%-2%), while those with malnutrition and respiratory infections had the highest (typically 3%-20%). Although there was significant heterogeneity between study populations and follow-up periods, studies consistently found rates of PDM to be similar, or to exceed, in-hospital mortality. Furthermore, over two-thirds of deaths after discharge occurred at home. Highly significant risk factors for PDM across all infectious admissions included HIV status, young age, pneumonia, malnutrition, anthropometric variables, hypoxia, anaemia, leaving hospital against medical advice and previous hospitalisations. CONCLUSIONS Postdischarge mortality rates are often as high as in-hospital mortality, yet remain largely unaddressed. Most children who die following discharge do so at home, suggesting that interventions applied prior to discharge are ideal to addressing this neglected cause of mortality. The development, therefore, of evidence-based, risk-guided, interventions must be a focus to achieve the sustainable development goals.
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Affiliation(s)
- Brooklyn Nemetchek
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lacey English
- Department of Medicine, University of North Carolina, Raleigh, North Carolina, USA
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - John Mark Ansermino
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
- Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - Peter P Moschovis
- Division of Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jerome Kabakyenga
- Maternal, Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Susan Fowler-Kerry
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Elias Kumbakumba
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Matthew O Wiens
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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15
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Kwambai TK, Dhabangi A, Idro R, Opoka R, Kariuki S, Samuels AM, Desai M, van Hensbroek MB, John CC, Robberstad B, Wang D, Phiri K, Ter Kuile FO. Malaria chemoprevention with monthly dihydroartemisinin-piperaquine for the post-discharge management of severe anaemia in children aged less than 5 years in Uganda and Kenya: study protocol for a multi-centre, two-arm, randomised, placebo-controlled, superiority trial. Trials 2018; 19:610. [PMID: 30400934 PMCID: PMC6220494 DOI: 10.1186/s13063-018-2972-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 10/08/2018] [Indexed: 01/02/2023] Open
Abstract
Background Children hospitalised with severe anaemia in malaria endemic areas in Africa are at high risk of readmission or death within 6 months post-discharge. Currently, no strategy specifically addresses this period. In Malawi, 3 months of post-discharge malaria chemoprevention (PMC) with monthly treatment courses of artemether-lumefantrine given at discharge and at 1 and 2 months prevented 30% of all-cause readmissions by 6 months post-discharge. Another efficacy trial is needed before a policy of malaria chemoprevention can be considered for the post-discharge management of severe anaemia in children under 5 years of age living in malaria endemic areas. Objective We aim to determine if 3 months of PMC with monthly 3-day treatment courses of dihydroartemisinin-piperaquine is safe and superior to a single 3-day treatment course with artemether-lumefantrine provided as part of standard in-hospital care in reducing all-cause readmissions and deaths (composite primary endpoint) by 6 months in the post-discharge management of children less than 5 years of age admitted with severe anaemia of any or undetermined cause. Methods/design This is a multi-centre, two-arm, placebo-controlled, individually randomised trial in children under 5 years of age recently discharged following management for severe anaemia. Children in both arms will receive standard in-hospital care for severe anaemia and a 3-day course of artemether-lumefantrine at discharge. At 2 weeks after discharge, surviving children will be randomised to receive either 3-day courses of dihydroartemisinin-piperaquine at 2, 6 and 10 weeks or an identical placebo and followed for 26 weeks through passive case detection. The trial will be conducted in hospitals in malaria endemic areas in Kenya and Uganda. The study is designed to detect a 25% reduction in the incidence of all-cause readmissions or death (composite primary outcome) from 1152 to 864 per 1000 child years (power 80%, α = 0.05) and requires 520 children per arm (1040 total children). Results Participant recruitment started in May 2016 and is ongoing. Trial registration ClinicalTrials.gov, NCT02671175. Registered on 28 January 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2972-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Titus K Kwambai
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research (CGHR), PO Box 1578, Kisumu, 40100, Kenya. .,Kisumu County Department of Health, Kenya Ministry of Health, Kisumu, Kenya. .,Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK.
| | - Aggrey Dhabangi
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Idro
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Opoka
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research (CGHR), PO Box 1578, Kisumu, 40100, Kenya
| | - Aaron M Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Michael Boele van Hensbroek
- Department of Global Child Health, Emma Children's Hospital Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bjarne Robberstad
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Kamija Phiri
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Feiko O Ter Kuile
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research (CGHR), PO Box 1578, Kisumu, 40100, Kenya.,Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
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