WHO Working Group on Health Literacy in Schools

Background

Addressing children`s and adolescents` health literacy is a bedrock for personal and societal growth, health and wellbeing over the life-course, and sustainable development in the WHO European Region and beyond. Promoting health literacy competencies should already be addressed in schools. To outline a strategy for the national education sectors, WHO Europe has launched a working group on health literacy in schools, which aims to develop a conceptual framework for decision makers within the educational and health sector to advocate for health literacy, facilitate the implementation process, and support the uptake on the national level.

Methods

Based on expert workshops and meetings, literature and document analyses and discussions, this working group has developed a concept note on health literacy addressing the education sector of the WHO member states.

Results

This work is linking health literacy in schools with the wider WHO health literacy strategy. Emphasis is placed on the critical role of the education sector and the necessary resources to implement action in schools. In addition, this report provides curriculum examples from Member States and key health literacy learning objectives. This includes an action agenda in order to implement monitoring and surveillance of health literacy in schools. The concept paper acknowledges the large variation in the level and organizational structure of the school health services among the 53 regional Member States.

Conclusions

This report highlights the reason why health literacy of children and adolescents should be addressed as early as in schools. It outlines the available evidence on children and adolescent`s health literacy and the challenges the Member States might face when they aim at addressing health literacy in the education sector and schools. The report should help policy and decision makers to implement health literacy in their countries taking into consideration the importance of adapting to local contexts.

Challenges to the implementation of the integrated management of childhood illness (IMCI) at community health centres in West Java province, Indonesia

BACKGROUND

The integrated management of childhood illness (IMCI) is a comprehensive approach to child health, which has been adopted in Indonesia since 1997. This study aims to provide an overview of IMCI implementation at community health centres (puskesmas) in West Java province, Indonesia.

METHODS

Data were derived from a cross-sectional study conducted in 10 districts of West Java province, from November to December 2012. Semi-structured interviews were used to obtain information from staff at 80 puskesmas, including the heads (80 informants), pharmacy staff (79 informants) and midwives/nurses trained in IMCI (148 informants), using semi-structured interviews. Quantitative data were analysed using frequency tabulations and qualitative data were analysed by identifying themes that emerged in informants' responses.

RESULTS

Almost all (N = 79) puskesmas implemented the IMCI strategy; however, only 64% applied it to all visiting children. Several barriers to IMCI implementation were identified, including shortage of health workers trained in IMCI (only 43% of puskesmas had all health workers in the child care unit trained in IMCI and 40% of puskesmas conducted on-the-job training). Only 19% of puskesmas had all the essential drugs and equipment for IMCI. Nearly all health workers acknowledged the importance of IMCI in their routine services and very few did not perceive its benefits. Lack of supervision from district health office staff and low community awareness regarding the importance of IMCI were reported. Complaints received from patients'families were generally related to the long duration of treatment and no administration of medication after physical examination.

CONCLUSION

Interventions aiming to create local regulations endorsing IMCI implementation; promoting monitoring and supervision; encouraging on-the-job training for health workers; and strengthening training programmes, counselling and other promotional activities are important for promoting IMCI implementation in West Java province, and are also likely to be useful elsewhere in the country.

The functioning of oxygen concentrators in resource-limited settings: a situation assessment in two countries

SETTING

The paediatric wards of hospitals in Malawi and Mongolia.

OBJECTIVE

To describe oxygen concentrator functioning in two countries with widespread, long-term use of concentrators as a primary source of oxygen for treating children.

DESIGN

A systematic assessment of concentrators in the paediatric wards of 15 hospitals in Malawi and nine hospitals in Mongolia.

RESULTS

Oxygen concentrators had been installed for a median of 48 months (interquartile range [IQR] 6-60) and 36 months (IQR 12-96), respectively, prior to the evaluation in Malawi and Mongolia. Concentrators were the primary source of oxygen. Three quarters of the concentrators assessed in Malawi (28/36) and half those assessed in Mongolia (13/25) were functional. Concentrators were found to remain functional with up to 30 000 h of use. However, several concentrators were functioning very poorly despite limited use. Concentrators from a number of different manufacturers were evaluated, and there was marked variation in performance between brands. Inadequate resources for maintenance were reported in both countries.

CONCLUSION

Years after installation of oxygen concentrators, many machines were still functioning, indicating that widespread use can be sustained in resource-limited settings. However, concentrator performance varied substantially. Procurement of high-quality and appropriate equipment is critical, and resources should be made available for ongoing maintenance.

Clinical manifestations and outcome in HIV-infected young infants presenting with acute illness in Durban, South Africa

OBJECTIVES

In young infants, early development of symptomatic HIV infection increases the risk of morbidity and mortality. A prospective study was conducted over a 1-year period in a region with a high burden of HIV in order to describe the clinical presentation of HIV infection in infants aged between 0 and 59 days on attendance at hospital and the factors associated with the need for urgent hospital management.

METHODS

Sick young infants presenting to the King Edward VIII Hospital, Durban between February 2003 and January 2004 were enrolled. After systematic evaluation by a primary health worker, an experienced paediatrician determined the primary diagnosis and need for urgent hospital management. Comparisons of these assessments were stratified by HIV status. Children were classified as HIV-uninfected (HIV ELISA-negative), HIV-exposed-but-uninfected (HIV ELISA-positive and HIV RNA PCR-negative), HIV-infected (HIV ELISA-positive and HIV viral load >400 copies/ml).

RESULTS

Of 925 infants enrolled, 652 (70·5%) had their HIV status determined: 70 (10·7%) were HIV-infected, 271 (41·6%) HIV-exposed-but-uninfected, and 311 (47·7%) HIV-uninfected. Factors associated with an increased probability of being HIV-infected included if the mother had children from more than one sexual partner, if the infant had had contact with a tuberculosis-infected person or if the HIV-infected mother and/or her exposed infant failed to receive nevirapine prophylaxis. Signs of severe illness were more frequently encountered in HIV-infected than in HIV-exposed-but-uninfected infants, including the prevalence of chest in-drawing (20·3% vs 8·8%, p = 0·004) and severe skin pustules (18·6% vs 8·6%, p = 0·01). Among infants requiring urgent hospital management, observed or reported feeding difficulties and severe skin pustules were more common in HIV-infected than uninfected infants. More HIV-infected infants (12·9%) required hospitalisation than those who were HIV-exposed-but-uninfected (7·7%) or uninfected (7·4%). Primary diagnoses of pneumonia, sepsis or oral thrush were more frequently seen in HIV-infected than exposed-but-uninfected or HIV-uninfected children.

CONCLUSION

Early recognition and triaging of infants suspected of having HIV infection provides an opportunity for early diagnosis and treatment which could prevent the adverse impact of rapidly progressive HIV disease.

Clinical profile and predictors of severe illness in young South African infants (<60 days)

BACKGROUND

Most childhood deaths occur within the first 2 months of life. Simple symptoms and signs that reliably indicate the presence of severe illness that would warrant urgent hospital management are of major public health importance.

OBJECTIVES

To describe the disease profile of sick young infants aged 0-59 days presenting at King Edward VIII Hospital, Durban, and to assess the association between clinical features assessed by primary health workers and the presence of severe illness.

METHODS

Specific clinical signs were evaluated in young infants by a health worker (nurse), using a standardised list. These signs were compared with an assessment by an experienced paediatrician for the need for urgent hospital- or clinic-based care.

RESULTS

Nine hundred and twenty-five young infants were enrolled; 61 were <7 days old, 477 were 7-27 days old, and 387 were 28-59 days old. Illnesses needing urgent hospital management in the age group <7 days were hyperbilirubinaemia (43%) and sepsis (43%); in the age group 7-27 days they were pneumonia (26%), sepsis (17%) and hyperbilirubinaemia (15%), and in the age group 28-59 days they were pneumonia (54%) and sepsis (15%). The clinical sign most consistently predictive of needing urgent hospital care across all groups was not feeding well. Among those over 7 days old, a history of difficult feeding, temperature 237.5 degrees C and respiratory rate > or =60 per minute were also important.

CONCLUSIONS

The simple features of feeding difficulties, pyrexia, tachypnoea and lower chest in-drawing are useful predictors of severity of illness as well as effective and safe tools for triaging of young infants for urgent hospital management at primary care centres. Neonatal hyperbilirubinaemia, pneumonia and sepsis are the common conditions for which young infants require urgent hospital-based management.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Dengue research and training supported through the World Health Organization

The rapidly increasing burden of dengue, the varied and often poorly understood factors contributing to its global spread, and the challenges of preventing and controlling it have led to a renewed call for more research and training on the disease. The main aims are to improve vector control, case management, and primary prevention through vaccine development. The World Health Organization (WHO), through its inter-departmental working group on dengue, is actively engaged in supporting and co-ordinating the major research activities. The dengue research initiatives of the Special Programme for Research and Training in Tropical Diseases (TDR), other departments at the WHO's Geneva headquarters, the WHO's regional and country offices, and the organization's dengue-affected member states are summarized in this article. This intensified effort, in close collaboration with other stakeholders, is contributing towards the goals of reversing the current epidemiological trends and of reducing the global burden posed by dengue in all of its forms.

Severe respiratory syncytial virus infection in early life is associated with increased type 2 cytokine production in Gambian children

BACKGROUND

Severe respiratory syncytial virus (RSV) infection in early childhood has been associated with subsequent wheezing and atopy. The aim of this study was to test if severe RSV infection in early life was associated with an increase in type 2 cytokine production and atopy in Gambian children 5 years later.

METHODS

A cohort of children with severe RSV infection during the first year of life ('cases', n = 66) and without ('controls', n = 122) was followed-up at 5 years of age. Immediate hypersensitivity to common allergens, airway reactivity, serum IgE concentration and the production of IFN-gamma, IL-5 and IL-13 by lymphocytes activated in vitro with RSV F-G or control antigens was determined.

RESULTS

After adjustment for confounders, cases produced significantly higher concentrations of IL-13 in response to RSV F-G and of IL-5 and IL-13 in response to tuberculin. Cases were more likely to have presented with a wheezy lower respiratory tract infection in the first 3 years of life (adjusted odds ratio = 9.9; 95% CI 1.6-61.0), but not thereafter. Cases and controls had similar skin response to allergens, airway reactivity and serum IgE concentrations.

CONCLUSION

Severe RSV infection in early life is associated with a higher production of type 2 cytokines in Gambian children at 5 years of age. However this does not appear to result in increased risk of atopy or clinical allergy at that age.

Evaluation of clinical pallor in the identification and treatment of children with moderate and severe anaemia

BACKGROUND

Anaemia from malaria is a common problem in developing countries. Blood transfusion in developing countries is available in few hospitals. Children who are severely anaemic and may require urgent blood transfusion usually present to peripheral first-level health facilities from where they must be referred to hospitals. Since most peripheral facilities do not determine haemoglobin levels, the decision on referral has to be made on clinical grounds.

OBJECTIVES

To evaluate the sensitivity and specificity of clinical pallor of the palms, nailbeds, conjunctivae, buccal mucosa or tongue against haemoglobin values and their reproducibility among health workers.

METHODS

A total of 2540 children 2 months to 5 years of age presenting to a rural health centre in Ethiopia were enrolled. Clinically detected pallor was compared with measured blood haemoglobin concentrations.

RESULTS

Any anaemia (haemoglobin < 11 g/dl) was found in 61% of the children. Severe anaemia (haemoglobin < 5 g/dl) was found in 4%. The presence of any pallor clinically correlated with moderate anaemia (haemoglobin level < 8 g/dl) could be detected with a sensitivity of 95% and a specificity of 64-68% when the palm and nailbeds were used and a sensitivity of 84% and a specificity of 81% when the conjunctivae were used. Severe anaemia was detected clinically as severe pallor in 50-56% of cases (with a specificity of 95-96%). Agreement between physicians was highest for conjunctivae and nailbed pallor (87%) and lowest for palm pallor (73%). Using multivariate analysis, identification of a systolic ejection murmur or altered sensorium, the presence of splenomegaly or malarial parasitaemia were independently predictive of severe and moderately severe anaemia.

CONCLUSIONS

Moderate and severe anaemia can be identified clinically in most cases for treatment and referral purposes. A systolic ejection murmur, altered sensorium, the presence of splenomegaly or malarial parasitaemia may be used as additional tools in considering urgent referral for blood transfusion.

Outcome of meningitis caused by Streptococcus pneumoniae and Haemophilus influenzae type b in children in The Gambia

In developing countries, endemic childhood meningitis is a severe disease caused most commonly by Streptococcus pneumoniae or Haemophilus influenzae type b (Hib). Although many studies have shown that fatality rates associated with meningitis caused by these organisms are high in developing countries, little is known about the long-term outcome of survivors. The purpose of this study was to assess the importance of disabilities following pneumococcal and Hib meningitis in The Gambia. 257 children aged 0-12 years hospitalized between 1990 and 1995 with culture-proven S. pneumoniae (n = 134) or Hib (n = 123) meningitis were included retrospectively in the study. 48% of children with pneumococcal meningitis and 27% of children with Hib meningitis died whilst in hospital. Of the 160 survivors, 89 (55%) were followed up between September 1996 and October 1997. Of the children with pneumococcal meningitis that were traced, 58% had clinical sequelae; half of them had major disabilities preventing normal adaptation to social life. 38% of survivors of Hib meningitis had clinical sequelae, a quarter of whom had major disabilities. Major handicaps found were hearing loss, mental retardation, motor abnormalities and seizures. These data show that despite treatment with effective antibiotics, pneumococcal and Hib meningitis kill many Gambian children and leave many survivors with severe sequelae. Hib vaccination is now given routinely in The Gambia; an effective pneumococcal vaccine is needed.

Respiratory illness after severe respiratory syncytial virus disease in infancy in The Gambia

OBJECTIVE

To determine the frequency of later respiratory tract morbidity after respiratory syncytial virus (RSV) disease in infancy.

DESIGN

Cohort study with passive, clinic-based surveillance.

SETTING

Outpatient department in The Gambia.

SUBJECTS

One hundred five children admitted to the hospital with severe RSV disease (case cohort), 105 control children matched for age not admitted to the hospital during the previous RSV season (control cohort 1), and 102 control children born after the RSV season (control cohort 2).

MAIN OUTCOME MEASURES

Frequencies of pneumonia, wheezing, and hospital admission with acute lower respiratory tract infection.

RESULTS

Pneumonia was more common in case children than in both control groups (adjusted incidence rate ratio [IRR, 95% CI]: 3.80 [2.73, 6. 10]), as was wheezing (IRR 7.33 [3.10,17.54]), pneumonia or wheezing (IRR 3.96 [2.60, 6.04]), and admission with pneumonia or wheezing (IRR 3.40 [1.87, 6.15]). The incidence rate per 100 child-years for pneumonia in the dry season for 12-month-old children was 27 for case patients, 8.1 for control cohort 1, and 6.51 for control cohort 2. By 3 years of age, the rates had fallen to low levels in all groups.

CONCLUSIONS

Pneumonia and wheezing are significantly more common in children after RSV-associated lower respiratory tract disease than in control subjects, but the incidence declines rapidly with increasing age.

Biochemical and haematological variables in Gambian children with cerebral malaria

Biochemical and haematological measurements were made in Gambian children who satisfied the criteria for the diagnosis of cerebral malaria over a 3-year period. Biochemical and haematological values were available for 388 and 624 children, respectively. Biochemical signs of renal and hepatic dysfunction were found and these may have contributed in a cumulative way to the high mortality seen in the study children. Cerebral involvement in children with cerebral malaria is only one, though the most important, manifestation of a multi-organ disease.

Chloramphenicol pharmacokinetics in infants less than three months of age in the Philippines and The Gambia

BACKGROUND

The broad antimicrobial spectrum and affordable price of chloramphenicol make it an attractive first line treatment option for children with severe illnesses in developing countries. Little is known, however, about its pharmacokinetics in young infants in these settings.

METHODS

We studied infants younger than 3 months of age hospitalized in Manila, Philippines and The Gambia with possible severe bacterial infections likely to benefit from treatment with chloramphenicol. Infants in the first week of life received intramuscular doses of 25 mg/kg chloramphenicol once daily, twice daily in the second through fourth week of life and three times daily from 5 to 12 weeks of age. Blood samples were taken at 0.5, 1, 2 and 3 h after the first dose, 1 h before the second dose and before the repetition doses on subsequent days. In the Philippines a second group of infants was treated with oral chloramphenicol according to the same dosage schedule.

RESULTS

Thirty-eight infants received intramuscular chloramphenicol, and 20 received oral drug. Intramuscular administration resulted in therapeutic concentrations (10 to 25 microg/ml) in 73 to 86% of children in each of the three age groups in the first 6 h and in 50 to 80% on Days 2 and 3. Between 33 and 38% of children had potentially toxic values on Days 2 and 3. In contrast, after oral administration, only about one-half of the children reached therapeutic values in serum at any time up to Day 3 after start of treatment.

CONCLUSIONS

Intramuscular chloramphenicol can be used as a second line drug for the treatment of severe infections in infants younger than 90 days of age, where third generation cephalosporins are not available. It quickly achieves therapeutic values in a high proportion of children. However, severe infections should not be treated with oral chloramphenicol in this age group, because therapeutic serum concentrations were inconsistently achieved.

Clinical algorithm for malaria during low and high transmission seasons

OBJECTIVES

To assess the proportion of children with febrile disease who suffer from malaria and to identify clinical signs and symptoms that predict malaria during low and high transmission seasons.

STUDY DESIGN

2490 children aged 2 to 59 months presenting to a health centre in rural Ethiopia with fever had their history documented and the following investigations: clinical examination, diagnosis, haemoglobin measurement, and a blood smear for malaria parasites. Clinical findings were related to the presence of malaria parasitaemia.

RESULTS

Malaria contributed to 5.9% of all febrile cases from January to April and to 30.3% during the rest of the year. Prediction of malaria was improved by simple combinations of a few signs and symptoms. Fever with a history of previous malarial attack or absence of cough or a finding of pallor gave a sensitivity of 83% in the high risk season and 75% in the low risk season, with corresponding specificities of 51% and 60%; fever with a previous malaria attack or pallor or splenomegaly had sensitivities of 80% and 69% and specificities of 65% and 81% in high and low risk settings, respectively.

CONCLUSION

Better clinical definitions are possible for low malaria settings when microscopic examination cannot be done. Health workers should be trained to detect pallor and splenomegaly because these two signs improve the specificity for malaria.

Renal involvement in Gambian children with cerebral or mild malaria

Kidney function was studied in 80 Gambian children with cerebral malaria, 73 children with mild malaria, and in 19 children with other febrile illnesses. Serum creatinine was measured, and the excretion in urine of immunoglobulin G, transferrin, albumin and alpha 1 microglobulin was determined. Twenty-five percent of children with cerebral malaria, and 4% of children with mild malaria had an elevated serum creatinine above 62 mumol/l. Increased urinary protein excretion was frequent: 53% of children with cerebral malaria had a glomerulo-tubular pattern of protein excretion, and 46% a tubular pattern. Median albuminuria was 68 mg/l in children with cerebral malaria, 18 mg/l in children with mild malaria, and 9 mg/l in febrile children with other diseases (P < 0.0001). There was no significant association between the proteinuria and height of fever or the degree of parasitaemia, and there was no significant association between death and signs of renal impairment. Renal involvement is common in children with malaria in The Gambia, with prerenal, glomerular, and tubulo-interstitial factors contributing. It is more pronounced in children with cerebral malaria than in those with mild malaria. However, renal dysfunction is relatively mild and does not indicate a worse prognosis.

Risk factors for severe respiratory syncytial virus infection leading to hospital admission in children in the Western Region of The Gambia

BACKGROUND

Acute lower respiratory tract infections (ALRI) are the major cause of mortality and morbidity in young children worldwide. Respiratory syncytial virus (RSV) infection is the most important viral cause of severe ALRI but only a small proportion of children infected with this virus develop severe disease. To identify possible risk factors for severe RSV infection leading to hospital admission we have carried out a case-control study of Gambian children with RSV infection admitted to hospital.

METHODS

In all, 277 children admitted to three hospitals in the Western Region of The Gambia with lower respiratory tract infection due to RSV were compared with 364 control children matched for age and location of residence who had not been admitted to hospital with an ALRI during the RSV season. A detailed questionnaire covering a wide range of potential social, environmental and nutritional risk factors was administered to the child's guardian.

RESULTS

Cases came from larger or more crowded compounds than controls; increased risk was particularly associated with greater numbers of children in the age group 3-5 years living in the compound (odds ratio [OR] for > or =2 children in the age group 3-5 years = 9.1, 95% CI: 3.7-28). Cases were more likely to have a sibling who had died (OR = 3.4, 95% CI: 1.7-7). Controls were more likely to have been exposed to smoke from cooking fires (OR for the mother of cases cooking at least once daily = 0.31, 95% CI: 0.14-0.7). Other protective factors were father's nationality and some professions. Vegetables were included in the diet of controls more frequently than in that of cases (OR = 0.16, 95% CI: 0.06-0.46). Mothers of cases complained of asthma more frequently than mothers of controls, but the number of asthmatic mothers was small (4.2 versus 0.5%, P = 0.05).

CONCLUSIONS

Risk factors for severe RSV infection identified in this study are not amenable to public health interventions. Prevention of severe infection is likely to require the development of an effective vaccine.

Long-term morbidity and mortality following hypoxaemic lower respiratory tract infection in Gambian children

Acute lower respiratory infections (ALRI) are the main cause of death in young children worldwide. We report here the results of a study to determine the long-term survival of children admitted to hospital with severe pneumonia. The study was conducted on 190 Gambian children admitted to hospital in 1992-94 for ALRI who survived to discharge. Of these, 83 children were hypoxaemic and were treated with oxygen, and 107 were not. On follow-up in 1996-97, 62% were traced. Of the children with hypoxaemia, 8 had died, compared with 4 of those without. The mortality rates were 4.8 and, 2.2 deaths per 100 child-years of follow-up for hypoxaemic and non-hypoxaemic children, respectively (P = 0.2). Mortality was higher for children who had been malnourished (Z-score < -2) when seen in hospital (rate ratio = 3.2; 95% confidence interval (CI) = 1.03-10.29; P = 0.045). Children with younger siblings experienced less frequent subsequent respiratory infections (rate ratio for further hospitalization with respiratory illness = 0.15; 95% CI = 0.04-0.50; P = 0.002). Children in Gambia who survive hospital admission with hypoxaemic pneumonia have a good prognosis. Survival depends more on nutritional status than on having been hypoxaemic. Investment in oxygen therapy appears justified, and efforts should be made to improve nutrition in malnourished children with pneumonia.

Respiratory syncytial virus infection in tropical and developing countries

Little is known about the epidemiology of respiratory syncytial virus (RSV) infection in tropical and developing countries; the data currently available have been reviewed. In most studies, RSV was found to be the predominant viral cause of acute lower respiratory tract infections (ALRI) in childhood, being responsible for 27-96% of hospitalised cases (mean 65%) in which a virus was found. RSV infection is seasonal in most countries; outbreaks occur most frequently in the cold season in areas with temperate and Mediterranean climates and in the wet season in tropical countries with seasonal rainfall. The situation on islands and in areas of the inner tropics with perennial high rainfall is less clear-cut. The age group mainly affected by RSV in developing countries is children under 6 months of age (mean 39% of hospital patients with RSV). RSV-ALRI is slightly more common in boys than in girls. Very little information is available about the mortality of children infected with RSV, the frequency of bacterial co-infection, or the incidence of further wheezing after RSV. Further studies on RSV should address these questions in more detail. RSV is an important pathogen ill young children in tropical and developing countries and a frequent cause of hospital admission. Prevention of RSV infection by vaccination would have a significant impact on the incidence of ALRI in children in developing countries.

The clinical spectrum of respiratory syncytial virus disease in The Gambia

BACKGROUND

Respiratory syncytial virus (RSV) is a well-recognized cause of lower respiratory tract infections in early childhood in industrialized countries, but less is known about RSV infection in developing countries.

METHODS

Four outbreaks of RSV infection that occurred between 1993 and 1996 in The Gambia, West Africa, were studied. RSV was sought by immunofluorescent staining of nasopharyngeal aspirate samples among young children who presented with respiratory infections at three hospitals in the Western Region of the country.

RESULTS

Five hundred seventy-four children with RSV infection were identified. The median ages of children seen in 1993 through 1996 were 3, 7, 8 and 5 months, respectively. Sixty-two percent of children <6 months old were boys. Thirteen children (2.4%) had conditions considered to increase the risk of severe RSV infection. On physical examination crepitations were heard in 80% of the children admitted to hospital, whereas wheezes were heard in only 39%. Eighty (16%) children received oxygen because of hypoxemia. Nine of 255 blood cultures (3.5%) were positive: 4 Streptococcus pneumoniae; 2 Haemophilus influenzae type b; 2 Staphylococcus aureus; and 1 Enterobacter agglomerans. Thirteen children died (2.4%). During the 4 study years 90, 25, 75 and 95% of isolates typed were RSV Subgroup A, respectively.

CONCLUSIONS

RSV is a significant cause of lower respiratory tract infection in young children in The Gambia, causing epidemics of bronchiolitis. It poses a significant burden on the health system, especially through the demand for supplementary oxygen. The clinical spectrum of RSV disease in The Gambia is similar to that seen in developed countries; concomitant bacterial infections are uncommon.

Relation between severe malaria morbidity in children and level of Plasmodium falciparum transmission in Africa

BACKGROUND

Malaria remains a major cause of mortality and morbidity in Africa. Many approaches to malaria control involve reducing the chances of infection but little is known of the relations between parasite exposure and the development of effective clinical immunity so the long-term effect of such approaches to control on the pattern and frequency of malaria cannot be predicted.

METHODS

We have prospectively recorded paediatric admissions with severe malaria over three to five years from five discrete communities in The Gambia and Kenya. Demographic analysis of the communities exposed to disease risk allowed the estimation of age-specific rates for severe malaria. Within each community the exposure to Plasmodium falciparum infection was determined through repeated parasitological and serological surveys among children and infants. We used acute respiratory-tract infections (ARI) as a comparison.

FINDINGS

3556 malaria admissions were recorded for the five sites. Marked differences were observed in age, clinical spectrum and rates of severe malaria between the five sites. Paradoxically, the risks of severe disease in childhood were lowest among populations with the highest transmission intensities, and the highest disease risks were observed among populations exposed to low-to-moderate intensities of transmission. For severe malaria, for example, admission rates (per 1000 per year) for children up to their 10th birthday were estimated as 3.9, 25.8, 25.9, 16.7, and 18.0 in the five communities; the forces of infection estimated for those communities (new infections per infant per month) were 0.001, 0.034, 0.050, 0.093, and 0.176, respectively. Similar trends were noted for cerebral malaria and for severe malaria anaemia but not for ARI. Mean age of disease decreased with increasing transmission intensity.

INTERPRETATION

We propose that a critical determinant of life-time disease risk is the ability to develop clinical immunity early in life during a period when other protective mechanisms may operate. In highly endemic areas measures which reduce parasite transmission, and thus immunity, may lead to a change in both the clinical spectrum of severe disease and the overall burden of severe malaria morbidity.

Predictors of hypoxaemia in hospital admissions with acute lower respiratory tract infection in a developing country

Since oxygen has to be given to most children in developing countries on the basis of clinical signs without performing blood gas analyses, possible clinical predictors of hypoxaemia were studied. Sixty nine children between the ages of 2 months and 5 years admitted to hospital with acute lower respiratory tract infection and an oxygen saturation (Sao2) < 90% were compared with 67 children matched for age and diagnosis from the same referral hospital with an Sao2 of 90% or above (control group 1), and 44 unreferred children admitted to a secondary care hospital with acute lower respiratory infection (control group 2). Using multiple logistic regression analysis, sleepiness, arousal, quality of cry, cyanosis, head nodding, decreased air entry, nasal flaring, and upper arm circumference were found to be independent predictors of hypoxaemia on comparison of the cases with control group 1. Using a simple model of cyanosis or head nodding or not crying, the sensitivity to predict hypoxaemia was 59%, and the specificity 94% and 93% compared to control groups 1 and 2, respectively; 80% of the children with an Sao2 < 80% were identified by the combination of these signs. Over half of the children with hypoxaemia could be identified with a combination of three signs: extreme respiratory distress, cyanosis, and severely compromised general status. Further prospective validation of this model with other datasets is warranted. No other signs improved the sensitivity without compromising specificity. If a higher sensitivity is required, pulse oximetry has to be used.

Pallor as a clinical sign of severe anaemia in children: an investigation in the Gambia

Anaemia associated with malaria is a major public health problem in African countries. Since most primary health facilities have to rely on physical signs and not laboratory tests to detect anaemic patients who need referral for blood transfusion, we have assessed the reliability of simple clinical signs to predict severe anaemia. A trained field assistant examined 368 children admitted to a tertiary care hospital, assessing the pallor of their eyelids (conjunctiva), palms and nailbeds, counting the respiratory rate, and looking for signs of respiratory distress. After the children's admission, their packed cell volume (PCV) was measured, and the need for transfusion and the outcomes were noted. A second observer examined 173 of these children so that interobserver variability in the detection of clinical signs could be assessed. A total of 27% of the 368 children had a PCV of < 15%. In a multiple regression analysis, definite pallor of the conjunctiva, definite pallor of the palms, and a "sick" appearance of the child were identified as independent significant predictors of a PCV of < 15%. The best predictor was a combination of definite pallor of the conjunctiva and pallor of the palms, with a sensitivity of 80% and a specificity of 85%. Inclusion of signs of respiratory distress did not improve the prediction. Pallor was a reproducible sign (weighted kappa statistic for the comparison between two observers: kappa = 0.6 for conjunctival pallor). We conclude that pallor can be used as a sign for referring children who may require blood transfusion.

Evaluation of an algorithm for the integrated management of childhood illness in an area with seasonal malaria in the Gambia

Most of the 12.4 million deaths occurring every year among under-5-year-olds in developing countries could be prevented by the application of simple treatment strategies. So that health professionals who have had limited training can identify and classify the common childhood diseases, WHO developed a treatment algorithm (the Integrated Management of Childhood Illness (IMCI) or Sick Child algorithm), a prototype of which was tested in 440 Gambian children aged between 2 months and 5 years. The children were first assessed by a trained field worker using the algorithm, and then by a paediatrician whose clinical diagnosis was supported by laboratory investigations and, when indicated, a chest X-ray. Compared with the paediatrician's diagnosis, the sensitivity and specificity of the draft IMCI algorithm were, respectively, 81% and 89% for the detection of pneumonia, 67% and 96% for dehydration, 87% and 8% for malaria parasitaemia (any level), 100% and 9% for malaria parasitaemia (above 5000 parasites/microliter), 100% and 99% for measles, 31% and 97% for otitis media, and 89% and 90% for malnutrition. Among the children admitted by the physician, 45% had been recommended for admission by the algorithm. Intermittent fever, chills and sweats did not help in discriminating between malaria and non-malarious fevers; shivering or shaking of the body had a sensitivity of only 35%. While the algorithm dealt with the majority of presenting complaints, the most common problems not addressed by the chart were skin rashes (21%), mouth problems (8%), and eye problems (6%). The draft IMCI algorithm proved to be effective in the diagnosis of pneumonia, gastroenteritis, measles and malnutrition, but not malaria where its use without microscopy would result in considerable over-treatment, especially in a low transmission area or during a low transmission season in countries with seasonal malaria. The current algorithm would benefit from expansion to cover management of localized infections as well as skin, mouth and eye problems.

Humidification of oxygen with unheated humidifiers in tropical climates

In developing countries, oxygen therapy in hospitals is frequently humidified with unheated bubble-through humidifiers. We assessed the efficacy of humidification under such circumstances. The water temperature in the humidifier and the ambient air temperature were measured and compared to the oxygen flow rate. It was calculated that oxygen was cooled in the humidifier by 6.12 degrees C (95% CI: 5.88; 6.35) per liter of flow for flow rates up to 2 l/min. Using the average temperatures on the hospital ward in January and August, and the WHO-recommended flow rates of 0.5 l/min and 1 l/min, the relative humidity of the oxygen delivered to a child was estimated to be between 34% and 56%. We conclude that unheated bubble-through humidifiers achieve low humidity in oxygen in tropical climates. Some of the complications associated with the use of nasopharyngeal catheters for the delivery of oxygen might be explained by this, as oxygen of low humidity and temperature is delivered directly into the posterior nasopharynx.

Comparison of nasal prongs and nasopharyngeal catheter for the delivery of oxygen in children with hypoxemia because of a lower respiratory tract infection

OBJECTIVE

To determine the best method of oxygen delivery for children in developing countries who have hypoxemia caused by acute lower respiratory tract infection.

METHODS

One hundred eighteen children between 7 days and 5 years of age with a lower respiratory tract infection and arterial hemoglobin oxygen saturation (Sao2) less than 90% were randomly selected to receive oxygen by nasopharyngeal (NP) catheter (n = 56) or nasal prongs (n = 62). A crossover study to determine the flow rate necessary to achieve an Sao2 of 95% was performed in 60 children.

RESULTS

One hundred twelve children could be oxygenated by the allocated method; in six oxygenation was poor with either method. The mean duration of therapy was 87.5 hours for the prongs and 94.9 hours for the NP catheter (not significant). The median oxygen consumption was 2142 L for prongs and 1692 L for the NP catheter (not significant). In the crossover study the prongs needed, on average, 26% higher oxygen flow rates than the NP catheter to obtain an Sao2 of 95% (p = 0.003). Complete nasal obstruction was observed in 24 of the children (44%) in the NP catheter group and in 8 (13%) in the prongs group (p < 0.001). Eighteen children died, 11 with NP catheter and 7 with prongs (not significant).

CONCLUSIONS

Because nasal prongs are less prone to complications, and oxygenation in children is equally effective, they are a more appropriate method than the NP catheter for oxygen delivery to children in developing countries with acute lower respiratory tract infections.

Results of surgical procedures for the correction of foot-drop and of lagophthalmus due to leprosy

Leprosy mutilations of the muscles and skeleton can be relieved by reconstructive surgery, but evaluation of the results of these operations is seldom undertaken. Between 1975 and 1984, 59 leprosy patients were operated on at the Marie Adelaide Leprosy Centre, Karachi, Pakistan, for lagophthalmus with the transposition of the posterior tibial muscle. We were able to re-examine 39 patients: tibialis posterior transposition was performed 25 times, and temporalis transposition was carried out 33 times; 18 of the 25 patients with the tibialis posterior transposition were pleased with the result, 7 were not: 21 patients could extend their feet above the neutral position; 24 of the patients with the temporalis transposition were satisfied, 9 were not: complete closure was demonstrated in 21 eyes; Persistent corneal damage was noted in 15 eyes; 12 of the 23 male patients cared for themselves, 16 lived with their families; 7 of the 8 female patients lived with their families. The results of the rehabilitation, in relation to the degree of mutilation, are considered satisfactory for a developing country. These surgical procedures give a good result, provided they are followed by intensive physiotherapy.

Renal failure is a common complication in non-immune Europeans with Plasmodium falciparum malaria

Renal failure in malaria appears to be a complication less well known than anaemia and cerebral malaria. Thirty-one non-immune patients treated for Plasmodium falciparum malaria at Hannover Medical School were reviewed. Nine patients (29%) had acute renal failure, seven of whom required dialysis, and five patients needed mechanical ventilation. Cerebral symptoms were seen in nine patients, and three of the patients died. In a second series, information about patients who died of malaria in Germany and Austria was gathered. Thirty-six reports were obtained and analysed retrospectively. Thirty-four patients (94%) had acute renal failure. Eighteen patients received dialysis while five other patients with high central venous pressure or hyperkalaemia would have benefitted from dialysis. Cerebral involvement was seen in 34 patients, and 20 patients showed respiratory failure. It was concluded that renal failure in P. falciparum malaria is as common in non-immune adults as cerebral malaria. As untreated renal failure may have a deleterious influence on cerebral and respiratory functions, early dialysis-treatment in patients with severe P. falciparum malaria and signs of deteriorating renal function is recommended.

The persistent trigeminal artery and its topographical relations

The topographical relation of a persistent trigeminal artery (PTA) to neighboring structures was investigated. The vessel belongs to Saltzman's type I. It originates from segment C5 of the internal carotid artery and opens into the basilar artery, 8 mm before the bifurcation into the two posterior cerebral arteries. The 6th cranial nerve winds around the first part of the PTA which is situated within Parkinson's triangle.