Unnecessary hospitalisations and polypharmacy practices in Romania: A health system evaluation for strengthening primary health care

Background

Children and pregnant women usually have multiple contacts with the health care system. While most conditions can be managed by primary health care (PHC) providers, hospitalisations are nevertheless common and often unjustified. The number of hospitalizations decreased in Romania at the start of the COVID-19 pandemic. While this is likely due to the disruption of health services and public health measures established to limit the spread of COVID-19, it also suggests that a proportion of hospitalisations prior to the pandemic were unnecessary. This healthcare system evaluation in Romania quantified unnecessary and unnecessarily prolonged hospitalisations in children, pregnant women and women hospitalised for delivery, and assessed antibiotic and polypharmacy practices in these groups.

Methods

We conducted the healthcare system evaluation in 10 hospitals across the country. We extracted data from medical records of patients hospitalized between 2019 and 2020. In each hospital, we randomly selected 40 medical records for each of the following groups: children 2-59 months of age, pregnant women, and women hospitalised for delivery. Clinical data were compared against WHO standards indicating a need for inpatient treatment or antibiotic therapy.

Results

Among 209 children and 349 pregnant women, unnecessary hospitalisations accounted for 57.9% and 56.2% of hospitalisations, respectively. Among necessary hospitalisations, a large proportion was unnecessarily prolonged, including 44.4% (n = 32/72) in children, 23.3% (n = 34/146) in pregnant women, and 45.8% (n = 110/240) in women after delivery. The proportion of unnecessary and unnecessarily prolonged hospitalisations did not differ between the pre-pandemic, the lockdown, and the post-lockdown periods. Antibiotics were prescribed to 53.1% (n = 43/81) of children with diarrhoea, while 50.8% (n = 61/120) of women with caesarean section received an unjustified prolonged course of antibiotics. Children and women were commonly prescribed unnecessary medications.

Conclusions

Findings of this evaluation should inform evidence-based decisions and actions for strengthening PHC and the healthcare system structure and improving the management of common diseases in mothers, newborns, and children. The evaluation should be repeated periodically to monitor progress.

Child and adolescent health in Europe: Towards meeting the 2030 agenda

Background

Childhood and adolescence are critical stages for a healthy life. To support countries in promoting health and development and improving health care for this age group, the WHO Regional Office for Europe developed the European strategy for child and adolescent health 2015-2020, which was adopted by all countries. This paper reports progress in the strategy's implementation until 2020.

Methods

A survey was sent to all ministries of health of the 53 Member States of the WHO European Region. Responses were received from 45 Member States. Results are presented in this paper.

Results

The European Region made overall progress in recent years, but increasing levels of overweight and obesity among children, adolescent mental health and low breastfeeding rates are recognized as key national challenges. Although forty-one countries adopted a national child and adolescent health strategy, only eight countries involve children in their review, development and implementation stages. Two-thirds of countries have a strategy for health-promoting schools and a school curriculum for health education. One-third of countries do not have legislation against marketing of unhealthy foods and beverages to children. Most countries reported routine assessment for developmental difficulties in children, but less than a quarter collected and reported data on children who are developmentally on track. There are major gaps in data collection for migrant children. Hospitalization rates for young children vary five-fold across the region, indicating over-hospitalization and access problems in some countries. Only ten countries allow minors access to health care without parental consent based on their maturity and only eleven countries allow school nurses to dispense contraceptives to adolescents without a doctor's prescription.

Conclusions

This paper shows the progress in child and adolescent health made by countries in Europe until 2020 and key areas where additional work is needed to move the 2030 agenda forward. The survey was undertaken before the COVID-19 pandemic and the war in Ukraine. Both will likely exacerbate many of the observed problems and potentially reverse some gains reported. A renewed commitment is needed.

Risk factors for community-acquired bacterial infection among young infants in South Asia: a longitudinal cohort study with nested case-control analysis

OBJECTIVE

Risk factors predisposing infants to community-acquired bacterial infections during the first 2 months of life are poorly understood in South Asia. Identifying risk factors for infection could lead to improved preventive measures and antibiotic stewardship.

METHODS

Five sites in Bangladesh, India and Pakistan enrolled mother-child pairs via population-based pregnancy surveillance by community health workers. Medical, sociodemographic and epidemiological risk factor data were collected. Young infants aged 0-59 days with signs of possible serious bacterial infection (pSBI) and age-matched controls provided blood and respiratory specimens that were analysed by blood culture and real-time PCR. These tests were used to build a Bayesian partial latent class model (PLCM) capable of attributing the probable cause of each infant's infection in the ANISA study. The collected risk factors from all mother-child pairs were classified and analysed against the PLCM using bivariate and stepwise logistic multivariable regression modelling to determine risk factors of probable bacterial infection.

RESULTS

Among 63 114 infants born, 14 655 were assessed and 6022 had signs of pSBI; of these, 81% (4859) provided blood samples for culture, 71% (4216) provided blood samples for quantitative PCR (qPCR) and 86% (5209) provided respiratory qPCR samples. Risk factors associated with bacterial-attributed infections included: low (relative risk (RR) 1.73, 95% credible interval (CrI) 1.42 to 2.11) and very low birth weight (RR 5.77, 95% CrI 3.73 to 8.94), male sex (RR 1.27, 95% CrI 1.07 to 1.52), breathing problems at birth (RR 2.50, 95% CrI 1.96 to 3.18), premature rupture of membranes (PROMs) (RR 1.27, 95% CrI 1.03 to 1.58) and being in the lowest three socioeconomic status quintiles (first RR 1.52, 95% CrI 1.07 to 2.16; second RR 1.41, 95% CrI 1.00 to 1.97; third RR 1.42, 95% CrI 1.01 to 1.99).

CONCLUSION

Distinct risk factors: birth weight, male sex, breathing problems at birth and PROM were significantly associated with the development of bacterial sepsis across South Asian community settings, supporting refined clinical discernment and targeted use of antimicrobials.

Dengue algorithms integrated into the IMCI guidelines: An updated assessment in five Southeast-Asian countries

Background

Dengue is not included explicitly in the WHO Integrated Management of Childhood Illness (IMCI) algorithm. However, the assessment, classification and management of dengue has been incorporated into several IMCI country adaptations. We aimed to evaluate the dengue algorithms incorporated into IMCI guidelines and discuss the need for harmonization, including an extension of the age range for IMCI.

Methods

This study included three steps. First, we investigated dengue algorithms incorporated into five Southeast-Asian (Myanmar, Philippines, Vietnam, Indonesia, Cambodia) country IMCI guidelines through a desk-based analysis. Second, we conducted an expert survey to elicit opinions regarding the integration of dengue and extension of the age range in IMCI. Third, we compared our findings with data from a large multicentric prospective study on acute febrile illness.

Results

We found considerable heterogeneity between the country specific IMCI guidelines in the dengue algorithms as well as classification schemes. Most guidelines did not differentiate between diagnostic algorithms for the detection of dengue versus other febrile illness, and warning signs for progression to severe dengue. Our expert survey resulted in a consensus to further integrate dengue in IMCI and extend the age range for IMCI guidelines beyond 5 years of age. Most of the interviewees responded that their country had a stand-alone clinical guideline for dengue, which was not integrated into the IMCI approach and considered laboratory testing for dengue necessary on day three of consecutive fever. Using data from a large multicentric study of children 5–15 years of age, we could confirm that the likelihood of dengue increased with consecutive fever days. However, a significant proportion of children (36%) would be missed if laboratory testing was only offered on the third consecutive day of fever.

Conclusions

This study supports the extension of the IMCI age range beyond 5 years of age as well as the inclusion of dengue relevant content in the algorithm. Because of the challenge of distinguishing dengue from other febrile illnesses, simple laboratory testing (e.g., full blood count) should be offered at an early stage during the course of the illness. Testing only children with consecutive fever over 3 days may lead to an underdiagnosis of dengue among those with acute febrile illness in children 5–15 years of age. In addition, specific laboratory testing for dengue should be made available to peripheral health facilities.

The Integrated Management of Childhood Illness (IMCI) was developed for the identification and treatment of major childhood illnesses based on a syndromic approach that can be applied by local health care workers in rural health facilities. Dengue represents an important differential diagnosis for children and adolescents with acute febrile illness in Southeast Asia but is not officially included in the fever module of IMCI. Local adaptations in different countries, however, have integrated dengue into their guidelines. We analysed the available local IMCI guidelines in Southeast Asia, conducted an expert survey, and investigated out findings using data from a large multicentric prospective study on acute febrile illness. Our findings support the extension of the age range for IMCI and the inclusion of dengue relevant content. When children presented with fever, the likelihood of dengue increased with consecutive fever days. We were able to quantify how likely dengue is as a cause of fever in children living in endemic areas, stratified by duration of fever. This evidence is useful for policy makers to consider the effect of more specific diagnostic tools for the monitoring of early dengue.

Moving Complementary Feeding Forward: Report on a Workshop of the Federation of International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) and the World Health Organization Regional Office for Europe

The WHO Regional Office for Europe and the Federation of International Societies for Pediatric Gastroenterology, Hepatology, and Nutrition held a joint workshop, "Moving Complementary Feeding Forward" at the sixth World Congress Pediatric Gastroenterology, Hepatology, and Nutrition in 2021. Here we summarize workshop presentations and discussions. The workshop covered health implications of complementary feeding (CF) including allergies, challenges to meet dietary needs during the CF period, quality of commercial complementary foods (CFD) and respective marketing practices, national CF guidelines in Europe, a nutrient profiling system for CFD, and global policy perspectives on the standards and regulation of marketing for CFD. Adequate CF practices are of critical importance for short and long-term child health, prevention of nutrient deficiencies, normal growth and development, and reducing the risk of allergies. The workshop identified the need to improve feeding practices, harmonize evidence-based information and develop guidance jointly with various stakeholders, improve the composition and marketing practices of commercial CFD and their transparent labeling based on nutrient profiling. Renewed efforts for collaboration between scientists, public health experts, pediatric associations, national governments, and the WHO are necessary for advancing progress.

Validation of visual estimation of neonatal jaundice in low-income and middle-income countries: a multicentre observational cohort study

OBJECTIVE

Determine the sensitivity and specificity of neonatal jaundice visual estimation by primary healthcare workers (PHWs) and physicians as predictors of hyperbilirubinaemia.

DESIGN

Multicentre observational cohort study.

SETTING

Hospitals in Chandigarh and Delhi, India; Dhaka, Bangladesh; Durban, South Africa; Kumasi, Ghana; La Paz, Bolivia.

PARTICIPANTS

Neonates aged 1-20 days (n=2642) who presented to hospitals for evaluation of acute illness. Infants referred for any reason from another health facility or those needing immediate cardiopulmonary resuscitation were excluded.

OUTCOME MEASURES

Infants were evaluated for distribution (head, trunk, distal extremities) and degree (mild, moderate, severe) of jaundice by PHWs and physicians. Serum bilirubin level was determined for infants with jaundice, and analyses of sensitivity and specificity of visual estimations of jaundice used bilirubin thresholds of >260 µmol/L (need for phototherapy) and >340 µmol/L (need for emergency intervention in at-risk and preterm babies).

RESULTS

1241 (47.0%) neonates had jaundice. High sensitivity for detecting neonates with serum bilirubin >340 µmol/L was found for 'any jaundice of the distal extremities (palms or soles) OR deep jaundice of the trunk or head' for both PHWs (89%-100%) and physicians (81%-100%) across study sites; specificity was more variable. 'Any jaundice of the distal extremities' identified by PHWs and physicians had sensitivity of 71%-100% and specificity of 55%-95%, excluding La Paz. For the bilirubin threshold >260 µmol/L, 'any jaundice of the distal extremities OR deep jaundice of the trunk or head' had the highest sensitivity across sites (PHWs: 58%-93%, physicians: 55%-98%).

CONCLUSIONS

In settings where serum bilirubin cannot be measured, neonates with any jaundice on the distal extremities should be referred to a hospital for evaluation and management, where delays in serum bilirubin measurement and appropriate treatment are anticipated following referral, the higher sensitivity sign, any jaundice on the distal extremities or deep jaundice of the trunk or head, may be preferred.

Childhood overweight and obesity abatement policies in Europe

Over the past two decades, a concerted effort to combat the rising tide of childhood overweight and obesity has taken shape. The World Health Organization (WHO) Commission on Ending Childhood Obesity (ECHO) provides recommendations for six priority areas of action, including the promotion of healthy food consumption, promotion of physical activity, preconception and pregnancy care, early childhood diet and physical activity, healthy nutrition and physical activity for school-aged children, and community-based weight management. This paper provides a snapshot of policies and measures aligned to these areas of action within the WHO European Region in order to encourage other countries to make similar efforts. Examples are drawn from Portugal (sugar-sweetened beverage tax, integrated nutrition strategy), the United Kingdom (soft drink levy, active commuting programs, urban design principles), Lithuania (prohibition of energy drinks), Norway (industry and government partnerships to promote healthier foods, nutrition education curriculum for schools), Hungary (tax subsidies to promote healthy diets), the European Union (cross-border marketing regulations, preconception and pregnancy care), Slovenia (food marketing restrictions), Spain (marketing restrictions within educational settings), Poland (investing in sports infrastructure), Russia (increasing sports participation), Estonia (redevelopment of the physical education curriculum), Netherlands (preconception and pregnancy care), Croatia (conditions to support breastfeeding), Austria (perinatal and early childhood nutrition), Czechia (life-course strategy), San Marino (nutrition and physical activity for school-aged children), Ukraine (potable water for schools), Ireland and Italy (community-based weight management approaches). Our findings suggest that a large disparity exists among the type and breadth of policies adopted by Member States, with a mix of single-issue policy responses and more cohesive strategies. The role of data, implementation research, and ongoing surveillance of country-level progress related to childhood overweight and obesity policies are discussed as an essential part of the iterative process of policy development. Additional work to systematically gather context-specific information on policy development, implementation, and reach according to ECHO's six areas of action by WHO European Region countries will inform future policy paradigms within the region.

Effects of the coronavirus disease 2019 pandemic and the policy response on childhood obesity risk factors: Gender and sex differences and recommendations for research

Childhood obesity is a public health concern globally, with generally higher prevalence rates in boys compared to girls. Although biological sex is an important determinant, gender roles and norms influence the exposure and vulnerability to risk factors for noncommunicable diseases. Norms and roles might be reinforced or change due to coronavirus disease 2019 (COVID-19) related measures as well as the exposure to risk factors for childhood obesity. COVID-19 related changes, such as home confinement, influence a child's risk of obesity. Using Dahlgren and Whitehead's model of the main determinants of health, this paper aims to provide a roadmap for future research on sex, gender, and childhood obesity during the time of COVID-19. It examines how COVID-19 has led to important changes in children's general socioeconomic, cultural, and environmental conditions, social and community networks, and individual lifestyle factors and how these may affect a child's risk for obesity. It focuses on the influence of gender and sex and outlines key considerations and indicators to examine in future studies concerned with promoting health and gender equity and equality. We need to understand the differential impact of COVID-19 related measures on girls' and boys' risk for obesity to adequately react with preventive measures, policies, and programs.

Thinness, overweight, and obesity in 6- to 9-year-old children from 36 countries: The World Health Organization European Childhood Obesity Surveillance Initiative-COSI 2015-2017

In 2015-2017, the fourth round of the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was conducted in 36 countries. National representative samples of children aged 6-9 (203,323) were measured by trained staff, with similar equipment and using a standardized protocol. This paper assesses the children's body weight status and compares the burden of childhood overweight, obesity, and thinness in Northern, Eastern, and Southern Europe and Central Asia. The results show great geographic variability in height, weight, and body mass index. On average, the children of Northern Europe were the tallest, those of Southern Europe the heaviest, and the children living in Central Asia the lightest and the shortest. Overall, 28.7% of boys and 26.5% of girls were overweight (including obesity) and 2.5% and 1.9%, respectively, were thin according to the WHO definitions. The prevalence of obesity varied from 1.8% of boys and 1.1% of girls in Tajikistan to 21.5% and 19.2%, respectively, in Cyprus, and tended to be higher for boys than for girls. Levels of thinness, stunting, and underweight were relatively low, except in Eastern Europe (for thinness) and in Central Asia. Despite the efforts to halt it, unhealthy weight status is still an important problem in the WHO European Region.

Urban and rural differences in frequency of fruit, vegetable, and soft drink consumption among 6-9-year-old children from 19 countries from the WHO European region

In order to address the paucity of evidence on the association between childhood eating habits and urbanization, this cross-sectional study describes urban-rural differences in frequency of fruit, vegetable, and soft drink consumption in 123,100 children aged 6-9 years from 19 countries participating in the fourth round (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents/caregivers completed food-frequency questionnaires. A multivariate multilevel logistic regression analysis was performed and revealed wide variability among countries and within macroregions for all indicators. The percentage of children attending rural schools ranged from 3% in Turkey to 70% in Turkmenistan. The prevalence of less healthy eating habits was high, with between 30-80% and 30-90% children not eating fruit or vegetables daily, respectively, and up to 45% consuming soft drinks on >3 days a week. For less than one third of the countries, children attending rural schools had higher odds (OR-range: 1.1-2.1) for not eating fruit or vegetables daily or consuming soft drinks >3 days a week compared to children attending urban schools. For the remainder of the countries no significant associations were observed. Both population-based interventions and policy strategies are necessary to improve access to healthy foods and increase healthy eating behaviors among children.

The integrated management of childhood illness (IMCI) and its potential to reduce the misuse of antibiotics

BACKGROUND

The Strategy of the Integrated Management of Childhood Illness (IMCI) was introduced in Central Asia and Europe to address the absence of evidence-based guidelines, the misuse of antibiotics, polypharmacy and over-hospitalization of children. A study carried out in 16 countries analysed the status and strengths of as well as the barriers to IMCI implementation and investigated how different health systems affect the problems IMCI aims to address. Here we present findings in relation to IMCI's effects on the rational use of drugs, particularly the improved rational use of antibiotics in children, the mechanisms through which these were achieved as well as counteracting system factors.

METHODS

220 key informants were interviewed ranging from 5 to 37 per country (median 12). Data was analysed for arising themes and peer-reviewed.

RESULTS

The implementation of IMCI led to improved prescribing patterns immediately after training of health workers according to key informants. IMCI provides standard treatment guidelines and an algorithmic diagnostic- and treatment-decision-tool for consistent decision-making. Doctors reported feeling empowered by the training to counsel parents and address their expectations and desire for invasive treatments and the use of multiple drugs. Improved prescribing patterns were not sustained over time but counteracted by factors such as: doctors prescribing antibiotics to create additional revenues or other benefits; aggressive marketing by pharmaceutical companies; parents pressuring doctors to prescribe antibiotics; and access to drugs without prescriptions.

CONCLUSIONS

Future efforts to improve child health outcomes must include: (1) the continued support to improve health worker performance to enable them to adhere to evidence-based treatment guidelines, (2) patient and parent education, (3) improved reimbursement schemes and prescription regulations and their consistent enforcement and (4) the integration of point-of-care tests differentiating between viral and bacterial infection into standards of care. Pre-requisites will be sufficient remuneration of health workers, sound training, improved health literacy among parents, conducive laws and regulations and reimbursement systems with adequate checks and balances to ensure the best possible care.

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.

Causes and incidence of community-acquired serious infections among young children in south Asia (ANISA): an observational cohort study

BACKGROUND

More than 500 000 neonatal deaths per year result from possible serious bacterial infections (pSBIs), but the causes are largely unknown. We investigated the incidence of community-acquired infections caused by specific organisms among neonates in south Asia.

METHODS

From 2011 to 2014, we identified babies through population-based pregnancy surveillance at five sites in Bangladesh, India, and Pakistan. Babies were visited at home by community health workers up to ten times from age 0 to 59 days. Illness meeting the WHO definition of pSBI and randomly selected healthy babies were referred to study physicians. The primary objective was to estimate proportions of specific infectious causes by blood culture and Custom TaqMan Array Cards molecular assay (Thermo Fisher, Bartlesville, OK, USA) of blood and respiratory samples.

FINDINGS

6022 pSBI episodes were identified among 63 114 babies (95·4 per 1000 livebirths). Causes were attributed in 28% of episodes (16% bacterial and 12% viral). Mean incidence of bacterial infections was 13·2 (95% credible interval [CrI] 11·2-15·6) per 1000 livebirths and of viral infections was 10·1 (9·4-11·6) per 1000 livebirths. The leading pathogen was respiratory syncytial virus (5·4, 95% CrI 4·8-6·3 episodes per 1000 livebirths), followed by Ureaplasma spp (2·4, 1·6-3·2 episodes per 1000 livebirths). Among babies who died, causes were attributed to 46% of pSBI episodes, among which 92% were bacterial. 85 (83%) of 102 blood culture isolates were susceptible to penicillin, ampicillin, gentamicin, or a combination of these drugs.

INTERPRETATION

Non-attribution of a cause in a high proportion of patients suggests that a substantial proportion of pSBI episodes might not have been due to infection. The predominance of bacterial causes among babies who died, however, indicates that appropriate prevention measures and management could substantially affect neonatal mortality. Susceptibility of bacterial isolates to first-line antibiotics emphasises the need for prudent and limited use of newer-generation antibiotics. Furthermore, the predominance of atypical bacteria we found and high incidence of respiratory syncytial virus indicated that changes in management strategies for treatment and prevention are needed. Given the burden of disease, prevention of respiratory syncytial virus would have a notable effect on the overall health system and achievement of Sustainable Development Goal.

FUNDING

Bill & Melinda Gates Foundation.

Causes of death among children aged 5-14 years in the WHO European Region: a systematic analysis for the Global Burden of Disease Study 2016

Background

The mortality burden in children aged 5–14 years in the WHO European Region has not been comprehensively studied. We assessed the distribution and trends of the main causes of death among children aged 5–9 years and 10–14 years from 1990 to 2016, for 51 countries in the WHO European Region.

Methods

We used data from vital registration systems, cancer registries, and police records from 1980 to 2016 to estimate cause-specific mortality using the Cause of Death Ensemble model.

Findings

For children aged 5–9 years, all-cause mortality rates (per 100 000 population) were estimated to be 46·3 (95% uncertainty interval [UI] 45·1–47·5) in 1990 and 19·5 (18·1–20·9) in 2016, reflecting a 58·0% (54·7–61·1) decline. For children aged 10–14 years, all-cause mortality rates (per 100 000 population) were 37·9 (37·3–38·6) in 1990 and 20·1 (18·8–21·3) in 2016, reflecting a 47·1% (43·8–50·4) decline. In 2016, we estimated 10 740 deaths (95% UI 9970–11 542) in children aged 5–9 years and 10 279 deaths (9652–10 897) in those aged 10–14 years in the WHO European Region. Injuries (road injuries, drowning, and other injuries) caused 4163 deaths (3820–4540; 38·7% of total deaths) in children aged 5–9 years and 4468 deaths (4162–4812; 43·5% of total) in those aged 10–14 years in 2016. Neoplasms caused 2161 deaths (1872–2406; 20·1% of total deaths) in children aged 5–9 years and 1943 deaths (1749–2101; 18·9% of total deaths) in those aged 10–14 years in 2016. Notable differences existed in cause-specific mortality rates between the European subregions, from a two-times difference for leukaemia to a 20-times difference for lower respiratory infections between the Commonwealth of Independent States (CIS) and EU15 (the 15 member states that had joined the European Union before May, 2004).

Interpretation

Marked progress has been made in reducing the mortality burden in children aged 5–14 years over the past 26 years in the WHO European Region. More deaths could be prevented, especially in CIS countries, through intervention and prevention efforts focusing on the leading causes of death, which are road injuries, drowning, and lower respiratory infections. The findings of our study could be used as a baseline to assess the effect of implementation of programmes and policies on child mortality burden.

Funding

WHO and Bill & Melinda Gates Foundation.

Assessing and Improving Children's Rights in Hospitals: Case Studies from Kyrgyzstan, Tajikistan, and Moldova

There is a recognized need to raise evidence on how to adopt human rights-based approaches (HRBAs) to health and to assess their impact. In 2013 and 2014, the World Health Organization (WHO) Regional Office for Europe used a set of tools to assess and improve the situation of children's rights in 11 hospitals in Kyrgyzstan, 10 hospitals in Tajikistan, and 21 hospitals in Moldova, by applying a HRBA to health, taking as a reference the Convention on the Rights of the Child (CRC). The assessment results show a similar situation across countries in some areas, and more or less significant variation in others. Common gaps include the need to improve adolescent-friendly health services, the rights to privacy and play; and infrastructure and equipment. In Kyrgyzstan and Tajikistan, a second round of assessment, was carried out, which showed an effective change in several areas, whilst other areas showed persistent gaps. Moldova did not carry out a second round of assessment. Involving children and parents in the assessment was crucial to obtain more reliable data; the project showed how to use the CRC as a framework to improve quality of care for children (QoC); and the tools were proven useful for self-assessment.

Implementation in Indonesia of the WHO Pocket Book of Hospital Care for Children

BACKGROUND

Effective implementation of evidence-based practice guidelines has the potential to improve quality of hospital care for children. To achieve this in Indonesia, a locally adapted version of the WHO Pocket Book of Hospital Care for Children was published in 2009.

OBJECTIVES

To document implementation of the Pocket Book in Indonesia and to compare uptake in health facilities in which there has been a quality-improvement approach involving audit and feedback with uptake in settings in which there has been only passive dissemination.

METHODS

Indonesian district health offices, district hospitals, health centres with beds, and medical schools were surveyed by telephone, and an online and telephone survey of paediatricians was conducted. Health facilities in four provinces were visited, and key stakeholders were interviewed. Health facilities were assessed on availability of the guidelines, use by staff, and their incorporation into hospital procedures and activities.

RESULTS

There was evidence of use of the Pocket Book across Indonesia, despite limited funding for implementation. Its distribution had reached all provinces; 61% (33/54) of health facilities surveyed had a copy of the guidelines. Hospitals involved in a related quality audit were more likely to report use of the guidelines than hospitals exposed to passive dissemination, although this difference was not significant. Of 150 paediatricians sampled, 109 (73%) reported referring to the guidelines in their clinical practice. The guidelines have been incorporated into the postgraduate paediatric curriculum in four of 13 universities sampled.

CONCLUSION

There was encouraging evidence of uptake of the Pocket Book in Indonesia following local adaptation, nationwide mailing distribution and small-scale local implementation activities.

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 use of CRP for diagnosing infections in young infants < 3 months of age in developing countries

The diagnosis of severe bacterial infection in young infants in developing countries is difficult because of the lack of sensitivity and specificity of the presenting symptoms and signs. Whether C-reactive protein (CRP) might help with the early detection of neonatal sepsis was investigated in a prospective study in The Gambia, Ethiopia and The Philippines. Infants < 3 months of age with symptoms or signs of possible sepsis were evaluated; CRP was measured and assessed for its ability to predict proven invasive bacterial infection. Of 966 children < 3 months of age, 54 had a positive blood culture, 13 a positive CSF culture, 15 a positive blood and CSF culture and 884 had negative cultures. Median (interquartile range) CRP values were 42 (9-173), 14 (6-36), 209 (135-286) and 8 (3-27) mg/L in the four groups, respectively. Taking a CRP cut-off of 10 mg/L, the sensitivity and specificity of an elevated CRP to predict a positive blood or CSF culture were 77% and 55%, respectively, and 55% and 82%, respectively, for a cut-off of 40 mg/L. CRP lacks the sensitivity and specificity to be used alone as a predictor of serious infections in young infants.

Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis

BACKGROUND

The annual number of hospital admissions and in-hospital deaths due to severe acute lower respiratory infections (ALRI) in young children worldwide is unknown. We aimed to estimate the incidence of admissions and deaths for such infections in children younger than 5 years in 2010.

METHODS

We estimated the incidence of admissions for severe and very severe ALRI in children younger than 5 years, stratified by age and region, with data from a systematic review of studies published between Jan 1, 1990, and March 31, 2012, and from 28 unpublished population-based studies. We applied these incidence estimates to population estimates for 2010, to calculate the global and regional burden in children admitted with severe ALRI in that year. We estimated in-hospital mortality due to severe and very severe ALRI by combining incidence estimates with case fatality ratios from hospital-based studies.

FINDINGS

We identified 89 eligible studies and estimated that in 2010, 11·9 million (95% CI 10·3-13·9 million) episodes of severe and 3·0 million (2·1-4·2 million) episodes of very severe ALRI resulted in hospital admissions in young children worldwide. Incidence was higher in boys than in girls, the sex disparity being greatest in South Asian studies. On the basis of data from 37 hospital studies reporting case fatality ratios for severe ALRI, we estimated that roughly 265,000 (95% CI 160,000-450,000) in-hospital deaths took place in young children, with 99% of these deaths in developing countries. Therefore, the data suggest that although 62% of children with severe ALRI are treated in hospitals, 81% of deaths happen outside hospitals.

INTERPRETATION

Severe ALRI is a substantial burden on health services worldwide and a major cause of hospital referral and admission in young children. Improved hospital access and reduced inequities, such as those related to sex and rural status, could substantially decrease mortality related to such infection. Community-based management of severe disease could be an important complementary strategy to reduce pneumonia mortality and health inequities.

FUNDING

WHO.

Assessment of the quality of hospital care for children in Indonesia

OBJECTIVES

To obtain an overview of the quality of care for children in Indonesia, by assessing hospitals with a view to proceed to a quality improvement mechanism for child care.

METHODS

Stratified two-stage random sampling in six regions identified 18 hospitals (provinces Jambi, East Java, Central Kalimantan, South-East Sulawesi, East Nusa Tenggara, North Maluku). Three randomly selected hospitals in each province were visited by trained assessors who scored each assessed service (expressed as a percentage of achievement) and grouped into good (≥ 80%), requiring improvement (60-79%) and urgently requiring improvement (< 60%).

RESULTS

The overall median result score across all areas was 43% (IQR 28%-53%). Case management for common childhood illnesses had a median score of 37% (IQR18-43%), neonatal care 46% (IQR 26-57%) and patient monitoring 40% (IQR 30-50%), all indicating an urgent need for improvement. Qualitative data showed as main problems inadequate use of standard treatment guidelines, irrational prescribing of antibiotics, poor progress monitoring and poor supportive care.

CONCLUSION

We found serious shortcomings in the quality of hospital care for children. Finding and documenting those is the first step in a quality improvement process. Work is needed to start an improvement cycle for hospital care.

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.

Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trial

BACKGROUND

Pneumonia causes more child deaths than does any other disease. Observational studies have indicated that smoke from household solid fuel is a significant risk factor that affects about half the world's children. We investigated whether an intervention to lower indoor wood smoke emissions would reduce pneumonia in children.

METHODS

We undertook a parallel randomised controlled trial in highland Guatemala, in a population using open indoor wood fires for cooking. We randomly assigned 534 households with a pregnant woman or young infant to receive a woodstove with chimney (n=269) or to remain as controls using open woodfires (n=265), by concealed permuted blocks of ten homes. Fieldworkers visited homes every week until children were aged 18 months to record the child's health status. Sick children with cough and fast breathing, or signs of severe illness were referred to study physicians, masked to intervention status, for clinical examination. The primary outcome was physician-diagnosed pneumonia, without use of a chest radiograph. Analysis was by intention to treat (ITT). Infant 48-h carbon monoxide measurements were used for exposure-response analysis after adjustment for covariates. This trial is registered, number ISRCTN29007941.

FINDINGS

During 29,125 child-weeks of surveillance of 265 intervention and 253 control children, there were 124 physician-diagnosed pneumonia cases in intervention households and 139 in control households (rate ratio [RR] 0·84, 95% CI 0·63-1·13; p=0·257). After multiple imputation, there were 149 cases in intervention households and 180 in controls (0·78, 0·59-1·06, p=0·095; reduction 22%, 95% CI -6% to 41%). ITT analysis was undertaken for secondary outcomes: all and severe fieldworker-assessed pneumonia; severe (hypoxaemic) physician-diagnosed pneumonia; and radiologically confirmed, RSV-negative, and RSV-positive pneumonia, both total and severe. We recorded significant reductions in the intervention group for three severe outcomes-fieldworker-assessed, physician-diagnosed, and RSV-negative pneumonia--but not for others. We identified no adverse effects from the intervention. The chimney stove reduced exposure by 50% on average (from 2·2 to 1·1 ppm carbon monoxide), but exposure distributions for the two groups overlapped substantially. In exposure-response analysis, a 50% exposure reduction was significantly associated with physician-diagnosed pneumonia (RR 0·82, 0·70-0·98), the greater precision resulting from less exposure misclassification compared with use of stove type alone in ITT analysis.

INTERPRETATION

In a population heavily exposed to wood smoke from cooking, a reduction in exposure achieved with chimney stoves did not significantly reduce physician-diagnosed pneumonia for children younger than 18 months. The significant reduction of a third in severe pneumonia, however, if confirmed, could have important implications for reduction of child mortality. The significant exposure-response associations contribute to causal inference and suggest that stove or fuel interventions producing lower average exposures than these chimney stoves might be needed to substantially reduce pneumonia in populations heavily exposed to biomass fuel air pollution.

FUNDING

US National Institute of Environmental Health Sciences and WHO.

The case for launch of an international DNA-based birth cohort study

The global health agenda beyond 2015 will inevitably need to broaden its focus from mortality reduction to the social determinants of deaths, growing inequities among children and mothers, and ensuring the sustainability of the progress made against the infectious diseases. New research tools, including technologies that enable high-throughput genetic and '-omics' research, could be deployed for better understanding of the aetiology of maternal and child health problems. The research needed to address those challenges will require conceptually different studies than those used in the past. It should be guided by stringent ethical frameworks related to the emerging collections of biological specimens and other health related information. We will aim to establish an international birth cohort which should assist low- and middle-income countries to use emerging genomic research technologies to address the main problems in maternal and child health, which are still major contributors to the burden of disease globally.

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.

Meeting oxygen needs in Africa: an options analysis from the Gambia

OBJECTIVE

To compare oxygen supply options for health facilities in the Gambia and develop a decision-making algorithm for choosing oxygen delivery systems in Africa and the rest of the developing world.

METHODS

Oxygen cylinders and concentrators were compared in terms of functionality and cost. Interviews with key informants using locally developed and adapted WHO instruments, operational assessments, cost-modelling and cost measurements were undertaken to determine whether oxygen cylinders or concentrators were the better choice. An algorithm and a software tool to guide the choice of oxygen delivery system were constructed.

FINDINGS

In the Gambia, oxygen concentrators have significant advantages compared to cylinders where power is reliable; in other settings, cylinders are preferable as long as transporting them is feasible. Cylinder costs are greatly influenced by leakage, which is common, whereas concentrator costs are affected by the cost of power far more than by capital costs. Only two of 12 facilities in the Gambia were found suitable for concentrators; at the remaining 10 facilities, cylinders were the better option.

CONCLUSION

Neither concentrators nor cylinders are well suited to every situation, but a simple options assessment can determine which is better in each setting. Nationally this would result in improved supply and lower costs by comparison with conventional cylinders alone, although ensuring a reliable supply would remain a challenge. The decision algorithm and software tool designed for the Gambia could be applied in other developing countries.

Clinical signs predicting severe illness in young infants (<60 days) in Bolivia

Identification of simple signs and symptoms that predict severe illness needing referral for admission of young infants is critical for reducing mortality in developing countries. Infants <2 months of age presenting to two hospitals in La Paz, Bolivia (n=1082) were evaluated by nurses for signs and symptoms, and independently by physicians for the need for admission. In young neonates, sensitivity of individual clinical signs was >35% for measured temperature ≥ 37.5° C (65%); all signs had specificity >85%. Odds ratios (ORs) for association of individual clinical signs with need for urgent hospital management were highest (>5) for history of difficulty feeding, not feeding well and fever. Clinical signs or symptoms are useful for primary healthcare workers to identify young infants with serious illness needing admission, and have been incorporated into the Integrated Management of Childhood Illness algorithm for use in Bolivia and elsewhere in Latin America.

Global burden of acute lower respiratory infections due to respiratory syncytial virus in young children: a systematic review and meta-analysis

BACKGROUND

The global burden of disease attributable to respiratory syncytial virus (RSV) remains unknown. We aimed to estimate the global incidence of and mortality from episodes of acute lower respiratory infection (ALRI) due to RSV in children younger than 5 years in 2005.

METHODS

We estimated the incidence of RSV-associated ALRI in children younger than 5 years, stratified by age, using data from a systematic review of studies published between January, 1995, and June, 2009, and ten unpublished population-based studies. We estimated possible boundaries for RSV-associated ALRI mortality by combining case fatality ratios with incidence estimates from hospital-based reports from published and unpublished studies and identifying studies with population-based data for RSV seasonality and monthly ALRI mortality.

FINDINGS

In 2005, an estimated 33.8 (95% CI 19.3-46.2) million new episodes of RSV-associated ALRI occurred worldwide in children younger than 5 years (22% of ALRI episodes), with at least 3.4 (2.8-4.3) million episodes representing severe RSV-associated ALRI necessitating hospital admission. We estimated that 66 000-199 000 children younger than 5 years died from RSV-associated ALRI in 2005, with 99% of these deaths occurring in developing countries. Incidence and mortality can vary substantially from year to year in any one setting.

INTERPRETATION

Globally, RSV is the most common cause of childhood ALRI and a major cause of admission to hospital as a result of severe ALRI. Mortality data suggest that RSV is an important cause of death in childhood from ALRI, after pneumococcal pneumonia and Haemophilus influenzae type b. The development of novel prevention and treatment strategies should be accelerated as a priority.

FUNDING

WHO; Bill & Melinda Gates Foundation.

Recommendations for treatment of childhood non-severe pneumonia

WHO recommendations for early antimicrobial treatment of childhood pneumonia have been effective in reducing childhood mortality, but the last major revision was over 10 years ago. The emergence of antimicrobial resistance, new pneumonia pathogens, and new drugs have prompted WHO to assemble an international panel to review the literature on childhood pneumonia and to develop evidence-based recommendations for the empirical treatment of non-severe pneumonia among children managed by first-level health providers. Treatment should target the bacterial causes most likely to lead to severe disease, including Streptoccocus pneumoniae and Haemophilus influenzae. The best first-line agent is amoxicillin, given twice daily for 3–5 days, although co-trimoxazole may be an alternative in some settings. Treatment failure should be defined in a child who develops signs warranting immediate referral or who does not have a decrease in respiratory rate after 48–72 h of therapy. If failure occurs, and no indication for immediate referral exists, possible explanations for failure should be systematically determined, including non-adherence to therapy and alternative diagnoses. If failure of the first-line agent remains a possible explanation, suitable second-line agents include high-dose amoxicillin–clavulanic acid with or without an affordable macrolide for children over 3 years of age.

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.

The role of Chlamydia pneumoniae in acute respiratory tract infections in young children in The Gambia, West Africa

BACKGROUND

Little is known about the role of Chlamydia pneumoniae in the aetiology of acute respiratory tract infections (ARI) in children in developing countries.

AIMS

To obtain better information, we studied the presence of C. pneumoniae and its association with clinical signs and symptoms of ARI in children under 5 years of age in The Gambia.

METHODS

C. pneumoniae was sought by polymerase chain reaction in nasopharyngeal secretions and/or lung puncture aspirates from 324 infants under 3 months of age and 325 children between 3 months and 5 years of age with malnutrition, with or without pneumonia, and in control children. Clinical signs and symptoms for ARI and the spectrum of other viral and bacterial organisms were compared between those positive for C. pneumoniae and those negative.

RESULTS

Of 324 young infants, ten (3.1%) showed the presence of C. pneumoniae whereas in the older children 50 of 325 (15%) were positive for C. pneumoniae. There was no significant association between clinical signs and symptoms of ARI and C. pneumoniae positivity in the young infants. Among older infants and children, there was a trend to more frequent lobar alveolar changes in those positive for C. pneumoniae. No bacterial pathogens were found to be significantly associated with C. pneumoniae infection. However, there was an association with measles in the malnutrition group and with RSV in the young infants group.

CONCLUSIONS

In this study, C. pneumoniae was not associated with any particular clinical syndrome. We found no evidence that the organism plays a major role in ARI in young children in developing countries such as The Gambia.

The spectrum of hypoxaemia in children admitted to hospital in The Gambia, West Africa

OBJECTIVE

Hypoxia predicts mortality in children with acute lower respiratory infections (ALRIs). We investigated the prevalence and predictive value of hypoxia in ALRI and other acute infectious diseases.

METHODS

We studied the spectrum of hypoxaemia in 4,047 children admitted to a tertiary hospital in The Gambia. Oxygen saturation was measured shortly after admission. Severe hypoxaemia was defined as an oxygen saturation below 90%.

RESULTS

5.8% of all admissions had severe hypoxaemia. Prevalence of hypoxaemia varied between disease groups: it was 11.7% in ALRI cases, 16.5% in neonates; 2.9% in malaria cases overall but 6.5% in cerebral malaria patients; and 2.7% in children with meningitis. Hypoxaemia predicted a poor outcome; the odds ratio for death among paediatric admissions overall was 7.45 [95% confidence intervals (CI) 5.40-10.29]. Surprisingly, it was lowest for children with ALRI [OR 3.53 (95% CI 1.13-10.59)], and higher for those with malaria 9.90 [95% CI 4.39-22.35].

CONCLUSION

Hypoxaemia is common among Gambian children admitted to hospital and it is often associated with a poor outcome. A similar situation is likely in many other developing countries. Thus, equipment for measuring oxygen saturation, and facilities and equipment for effective oxygen delivery need to be made available in developing countries.

Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment

BACKGROUND

Major concerns about the quality of basic hospital care for children have been raised in developing countries, but no formal assessment applying international standards has been done in the Commonwealth of Independent States.

METHODS

We assessed 17 hospitals in Kazakhstan, the Republic of Moldova, and the Russian Federation with a generic WHO hospital assessment framework adapted for use in the WHO European region. WHO management guidelines for paediatric care in peripheral hospitals were used as standards.

FINDINGS

Hospital access for children was generally good. Good health networks existed, and skilled and committed doctors cared for children. Case-fatality rates were low. However, unnecessary and lengthy hospital stays were common, and most children received excessive and ineffective treatment (in one country median number of drugs prescribed concurrently was 5, IQR 2-6). Several conditions were systematically overdiagnosed, especially neurological disease, or overinvestigated, such as acute diarrhoea. Reasons for these practices included absence of clear evidence-based clinical guidelines, regulations tying duration of admission to financial reimbursement, generalisation of disease-control methods from rare problems to common illnesses, and regulations maintaining financial and professional status of some subspecialties. Many disincentives to efficient practice existed.

INTERPRETATION

To improve quality of hospital care for children in the Commonwealth of Independent States, several issues must be addressed, including: adoption of international guidelines for inpatient management; complementary guidelines for outpatient management; reforms to health regulations governing admission and discharge criteria; improvement of quality of training, availability of medical information, and systems to promote and certify quality of care.