Les aspects actuels du paludisme grave de l’enfant en milieu hospitalier pédiatrique centrafricain

OBJECTIVE

The authors had for aim, to determine the frequency and the main clinical forms of severe malaria and to evaluate its management.

PATIENTS AND METHODS

A cross-sectional investigation was made in the "Complexe Pediatrique" of Bangui, the only children hospital of the CAR capital, from 12 January to 12 September 1998. The survey included children 6 months to 15 years of age presenting on admission with a positive thick drop examination, and at least one of the clinical symptoms of severe malaria as defined by the World Organization of Health (WHO).

RESULTS

Four hundred and thirty-two children were included. Those from 6 months to 4 years of age accounted for 89.35% of the studied population. The most frequent clinical forms were neurological 31% and anemic 22.2%; the other forms were combined in 42.8%. Managing patients consisted of an etiologic treatment by quinine (91.7%) or sulfadoxine pyrimethamine (3.2%) and symptomatic treatment in the following proportions: rehydration: 49.3%; blood transfusion: 36.3%; preventing seizure: 72.9%; oxygen therapy: 77.5%; use of antipyretics: 96.7%, and correction of hypoglycemia: 9%. The death rate remained high with 62 deaths (14.35%). It was higher in combined forms (48 deaths out of 62).

CONCLUSION

Severe malaria and its various clinical forms remain a major problem for our pediatric intensive care unit. Updated technical means and human resources could improve the management of severe pediatric malaria.

[In vivo evaluation of chloroquine therapeutic efficacy in uncomplicated Plasmodium falciparum malaria in Central African Republic ine 1997 and 1998]

The efficacy of oral chloroquine was assessed in 268 children aged from 6 to 59 months attending pediatric services in regional hospitals between September 1997 and December 1998, located in the five county towns of the sanitary regions of the Central African Republic. Chloroquine was prescribed at 25 mg per kg body weight, and administered over 3 days to patients suffering from uncomplicated malaria. Body temperature and blood smears including parasitaemia were recorded on days 0, 3, 7 and 14. The main objective of the present study was to evaluate the therapeutic efficacy of chloroquine in the treatment of uncomplicated malaria using in vivo tests according to the WHO protocol (1996). The secondary objective was to identify the predictive factors of chloroquine relapses. Early relapses rates were under 15% except in Bangui (40%). A recurrence of parasitaemia with fever, sign of late relapse, was noted in 9% of children in Bambari, 9% in Bangassou, 8% in Bangui, 5% in Bossangoa and 4% in Berberati. The rate of successfully treated patients was between 66% and 75% except in Bangui (36%). Only the places of study and anaemia in days 0 were significant predictive factors of therapeutic relapses. Since the emergence of chloroquine resistance cases to P. falciparum in 1983 in Central African Republic, the phenomenon has increased. According to our results, a strong chloroquine resistance appears in the capital Bangui. Therefore, chloroquine should be replaced there for the first line treatment of uncomplicated P. falciparum malaria. In the provinces, it doesn't seem necessary to change the current chloroquine-based first line treatment.

Predictors of correct treatment of children with fever seen at outpatient health facilities in the Central African Republic

To identify factors associated with improved performance of health care workers who treat ill children in developing countries, the authors analyzed a sample of consultations of children with malaria (defined as any fever) from a national health facility survey conducted in the Central African Republic from December 1995 to January 1996. Twenty-eight health care workers and 204 children were studied. A univariate analysis revealed the following significant predictors of correct treatment, as defined by the Central African malaria control program: high fever (odds ratio (OR) = 3.25, 95% confidence interval (CI): 1.47, 7.17); correct health care worker diagnosis (OR = 2.59, 95% CI: 1.39, 4.85); and the caregiver's reporting the child's fever to the health care worker (OR = 2.18, 95% CI: 1.32, 3.62). There was an unexpected inverse association between the presence of a fever treatment chart and correct treatment (OR = 0.19, 95% CI: 0.04, 0.91). Correct treatment was marginally associated with a longer consultation time (p value for trend = 0.058). Neither in-service training in the treatment of fever nor supervision was significantly associated with correct treatment. For child health programs to improve, targeted studies are needed to understand which factors, alone or in combination, improve health care worker performance.

Antimicrobial resistance of nasopharyngeal isolates of Streptococcus pneumoniae and Haemophilus influenzae from children in the Central African Republic

BACKGROUND

To assist the Central African Republic (CAR) develop national guidelines for treating children with pneumonia, a survey was conducted to determine antimicrobial resistance rates of nasopharyngeal isolates of Streptococcus pneumoniae (SP) and Haemophilus influenzae (HI). Secondary purposes of the survey were to identify risk factors associated with carriage of a resistant isolate and to compare the survey methods of including only children with pneumonia vs. including all ill children.

METHODS

A cross-sectional survey of 371 ill children was conducted at 2 outpatient clinics in Bangui, CAR.

RESULTS

In all 272 SP isolates and 73 HI isolates were cultured. SP resistance rates to penicillin, trimethoprim-sulfamethoxazole (TMP-SMX), tetracycline and chloramphenicol were 8.8, 6.3, 42.3 and 9.2%, respectively. All penicillin-resistant SP isolates were intermediately resistant. HI resistance rates to ampicillin, TMP-SMX and chloramphenicol were 1.4, 12.3 and 0%, respectively. The most common SP serotypes/groups were 19, 14, 6 and 1; 49% of HI isolates were type b. History of antimicrobial use in the previous 7 days was the only factor associated with carriage of a resistant isolate. Resistance rates were similar among ill children regardless of whether they had pneumonia.

CONCLUSIONS

Resistance rates were low for antimicrobials recommended by the World Health Organization for children with pneumonia. We recommended TMP-SMX as the first line treatment for pneumonia in CAR because of its low cost, ease of dosing and activity against malaria.

[Effectiveness of a water iodination system for preventing iodine deficiency diseases in Central Africa]

Iodine deficiency disorders are major problems in most developing countries. According to WHO more than one billion people worldwide are at risk for iodine deficiency. However, prophylaxis programs based on the distribution of iodized salt have been unsuccessful in developing countries for socioeconomic reasons. We tested the efficacy of iodination of water with sodium iodide incorporated into silicone matrices (Rhône-Poulenc-Rorer-Doma). Nine such matrices were placed into each of the 198 wells supplying more than 90% of the 85,037 inhabitants of the Nana-Grebizi prefecture (figure 1). Efficacy was evaluated by following classical markers of iodine deficiency in representative samples of the population (figure 2): goiter size was measured immediately before (T = 0, n = 3,090) and twelve months after (T = 12, n = 2,645) installation of the matrices; and urinary iodine concentrations were assayed at T = 0 (n = 319), 6 (n = 304) and 12 (n = 261). The prevalence of goiter was 60.9% (visible goiter 10.7%, cretinism 0.7%) and the median urinary iodine concentration was 2.1 (95% confidence interval 2.0-2.3) micrograms/dl. Thus the population suffered from severe iodine deficiency. All villages were severely affected, despite inter-village variations (tables 1 and 2, figure 4). Twelve months after iodination of wells, the overall prevalence of goiter fell to 44.5% (p < 0.0001, table 1 and figure 3) and that of visible goiter to 2.5% (p < 0.0001). With the exception of one village (Bokanzi) the prevalence of goiter decreased by 18.6 to 56.3% (table 1).(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the level of endemic tuberculosis in a survey of Banqui (Central African Republic)]

A cluster sample survey on tuberculosis has been carried out in Bangui in February 1988. The bimodal distribution of the diameters of IDR on children aged between 5 to 9, gives evidence of a circulation of some non typical mycobacteriae and enables to fix the limit of positivity at 14 mm. The prevalence rate of the tuberculotic infection is 7.9 +/- 1.7% in the surveyed children population at school. The annual risk of infection is evaluated at 1.09% that ranks the Centrafrican Republic in the countries with a low prevalence rate.

[Hematologic disorders in pregnant women in a health center in Bangui]

We investigated 101 pregnant women, looking at haematologic values (blood-cell count, haematocrit...) on blood samples and searching for intestinal parasites on stool samples. We found that first-time pregnant young ladies frequently suffer from anemia, mainly during the second and third trimester of their pregnancy. Infestation with ankylostoma duodenale is one of the major causes. Therefore our advice to fellow-physicians is to look at these haematologic values and stool exams quite routinely for a better care of all pregnant women from our areas.