Identifying exceptional malaria occurrences in the absence of historical data in South Sudan: a method validation

Background

Detecting unusual malaria events that may require an operational intervention is challenging, especially in endemic contexts with continuous transmission such as South Sudan. Médecins Sans Frontières (MSF) utilises the classic average plus standard deviation (AV+SD) method for malaria surveillance. This and other available approaches, however, rely on antecedent data, which are often missing.

Objective

To investigate whether a method using linear regression (LR) over only 8 weeks of retrospective data could be an alternative to AV+SD.

Design

In the absence of complete historical malaria data from South Sudan, data from weekly influenza reports from 19 Norwegian counties (2006-2015) were used as a testing data set to compare the performance of the LR and the AV+SD methods. The moving epidemic method was used as the gold standard. Subsequently, the LR method was applied in a case study on malaria occurrence in MSF facilities in South Sudan (2010-2016) to identify malaria events that required a MSF response.

Results

For the Norwegian influenza data, LR and AV+SD methods did not perform differently (P > 0.05). For the South Sudanese malaria data, the LR method identified historical periods when an operational response was mounted.

Conclusion

The LR method seems a plausible alternative to the AV+SD method in situations where retrospective data are missing.

Infection prevention and control in health facilities in post-Ebola Liberia: don't forget the private sector!

Setting: Recognising the importance of infection prevention and control (IPC), a minimum standards tool (MST) was developed in Liberia to guide the safe (re-) opening and provision of care in health facilities. Objectives: To analyse the implementation of specific IPC measures after the 2014 Ebola virus outbreak between June 2015 and May 2016, and to compare the relative improvements in IPC between the public and private sectors. Design: A retrospective comparative cohort study. Results: We evaluated 723 (94%) of the 769 health facilities in Liberia. Of these, 437 (60%) were public and 286 (40%) were private. There was an overall improvement in the MST scores from a median of 13 to 14 out of a maximum possible score of 16. While improvements were observed in all aspects of IPC in both public and private health facilities, IPC implementation was systematically higher in public facilities. Conclusions: We demonstrate the feasibility of monitoring IPC implementation using the MST checklist in post-Ebola Liberia. Our study shows that improvements were made in key aspects of IPC after 1 year of evaluations and tailored recommendations. We also highlight the need to increase the focus on the private sector to achieve further improvements in IPC.

Where technology does not go: specialised neonatal care in resource-poor and conflict-affected contexts

Setting: Although neonatal mortality is gradually decreasing worldwide, 98% of neonatal deaths occur in low- and middle-income countries, where hospital care for sick and premature neonates is often unavailable. Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) managed eight specialised neonatal care units (SNCUs) at district level in low-resource and conflict-affected settings in seven countries. Objective: To assess the performance of the MSF SNCU model across different settings in Africa and Southern Asia, and to describe the set-up of eight SNCUs, neonate characteristics and clinical outcomes among neonates from 2012 to 2015. Design: Multicentric descriptive study. Results: The MSF SNCU model was characterised by an absence of high-tech equipment and an emphasis on dedicated nursing and medical care. Focus was on the management of hypothermia, hypoglycaemia, feeding support and early identification/treatment of infection. Overall, 11 970 neonates were admitted, 41% of whom had low birthweight (<2500 g). The main diagnoses were low birthweight, asphyxia and neonatal infections. Overall mortality was 17%, with consistency across the sites. Chances of survival increased with higher birthweight. Conclusion: The standardised SNCU model was implemented across different contexts and showed in-patient outcomes within acceptable limits. Low-tech medical care for sick and premature neonates can and should be implemented at district hospital level in low-resource settings.

Knockdown and recovery of malaria diagnosis and treatment in Liberia during and after the 2014 Ebola outbreak

Setting: The malaria-endemic country of Liberia, before, during and after the 2014 Ebola outbreak. Objective: To describe the consequences of the Ebola outbreak on Liberia's National Malaria Programme and its post-Ebola recovery. Design: A retrospective cross-sectional study using routine countrywide programme data. Results: Malaria caseloads decreased by 47% during the Ebola outbreak and by 11% after, compared to the pre-Ebola period. In those counties most affected by Ebola, a caseload reduction of >20% was sustained for 12 consecutive months, while this lasted for only 4 consecutive months in the counties least affected by Ebola. Linear regression of monthly proportions of confirmed malaria cases-as a proxy indicator of programme performance-over the pre- and post-Ebola periods indicated that the malaria programme could require 26 months after the end of the acute phase of the Ebola outbreak to recover to pre-Ebola levels. Conclusions: The differential persistence of reduced caseloads in the least- and most-affected counties, all of which experienced similar emergency measures, suggest that factors other than Ebola-related security measures played a key role in the programme's reduced performance. Clear guidance on when to abandon the emergency measures after an outbreak may be needed to ensure faster recovery of malaria programme performance.

How do low-birthweight neonates fare 2 years after discharge from a low-technology neonatal care unit in a rural district hospital in Burundi?

OBJECTIVES

As neonatal care is being scaled up in economically poor settings, there is a need to know more on post-hospital discharge and longer-term outcomes. Of particular interest are mortality, prevalence of developmental impairments and malnutrition, all known to be worse in low-birthweight neonates (LBW, <2500 g). Getting a better handle on these parameters might justify and guide support interventions. Two years after hospital discharge, we thus assessed: mortality, developmental impairments and nutritional status of LBW children.

METHODS

Household survey of LBW neonates discharged from a neonatal special care unit in Rural Burundi between January and December 2012.

RESULTS

Of 146 LBW neonates, 23% could not be traced and 4% had died. Of the remaining 107 children (median age = 27 months), at least one developmental impairment was found in 27%, with 8% having at least five impairments. Main impairments included delays in motor development (17%) and in learning and speech (12%). Compared to LBW children (n = 100), very-low-birthweight (VLBW, <1500 g, n = 7) children had a significantly higher risk of impairments (intellectual - P = 0.001), needing constant supervision and creating a household burden (P = 0.009). Of all children (n-107), 18% were acutely malnourished, with a 3½ times higher risk in VLBWs (P = 0.02).

CONCLUSIONS

Reassuringly, most children were thriving 2 years after discharge. However, malnutrition was prevalent and one in three manifested developmental impairments (particularly VLBWs) echoing the need for support programmes. A considerable proportion of children could not be traced, and this emphasises the need for follow-up systems post-discharge.

Emergency obstetric care in a rural district of Burundi: What are the surgical needs?

OBJECTIVES

In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes.

METHODS

A retrospective analysis of EmOC data (2011 and 2012).

RESULTS

A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by 'general practitioners with surgical skills' and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died.

CONCLUSION

Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.

Sparks creating light? Strengthening peripheral disease surveillance in the Democratic Republic of Congo

SETTING

The Democratic Republic of Congo suffers from an amalgam of disease outbreaks and other medical emergencies. An efficient response to these relies strongly on the national surveillance system. The Pool d'Urgence Congo (PUC, Congo Emergency Team) of Médecins Sans Frontières is a project that responds to emergencies in highly remote areas through short-term vertical interventions, during which it uses the opportunity of its presence to reinforce the local surveillance system.

OBJECTIVE

To investigate whether the ancillary strengthening of the peripheral surveillance system during short-term interventions leads to improved disease notification.

DESIGN

A descriptive paired study measuring disease notification before and after 12 PUC interventions in 2013-2014.

RESULTS

A significant increase in disease notification was observed after seven mass-vaccination campaigns and was sustained over 6 months. For the remaining five smaller-scaled interventions, no significant effects were observed.

CONCLUSION

The observed improvements after even short-term interventions underline, on the one hand, how external emergency actors can positively affect the system through their punctuated actions, and, on the other hand, the dire need for investment in surveillance at peripheral level.

Building operational research capacity in the Pacific

Operational research (OR) in public health aims to investigate strategies, interventions, tools or knowledge that can enhance the quality, coverage, effectiveness or performance of health systems. Attention has recently been drawn to the lack of OR capacity in public health programmes throughout the Pacific Islands, despite considerable investment in implementation. This lack of ongoing and critical reflection may prevent health programme staff from understanding why programme objectives are not being fully achieved, and hinder long-term gains in public health. The International Union Against Tuberculosis and Lung Disease (The Union) has been collaborating with Pacific agencies to conduct OR courses based on the training model developed by The Union and Médecins Sans Frontières Brussels-Luxembourg in 2009. The first of these commenced in 2011 in collaboration with the Fiji National University, the Fiji Ministry of Health, the World Health Organization and other partners. The Union and the Secretariat of the Pacific Community organised a second course for participants from other Pacific Island countries and territories in 2012, and an additional course for Fijian participants commenced in 2013. Twelve participants enrolled in each of the three courses. Of the two courses completed by end 2013, 18 of 24 participants completed their OR and submitted papers by the course deadline, and 17 papers have been published to date. This article describes the context, process and outputs of the Pacific courses, as well as innovations, adaptations and challenges.

Providing a gateway to prevention and care for the most at-risk populations in Bhutan: is this being achieved?

SETTING

Two free-standing urban human immunodeficiency virus (HIV) testing and counselling (HCT) centres in Bhutan offering services to the general population and targeting the most at-risk populations (MARPs).

OBJECTIVES

To assess the trend in testing for HIV, hepatitis B and syphilis in both the general population and MARPs, and to determine if sociodemographic and risk behaviour characteristics are associated with HIV, hepatitis B and syphilis seropositivity.

DESIGN

Cross-sectional study using client records, 2009 - 2012.

RESULTS

Of 7894 clients, 3009 (38%) were from the general population, while 4885 (62%) were from MARPs. Over the 4-year period, testing declined progressively among the general population, while it increased or remained static for MARPs. Of 4885 MARPs, seropositivity was respectively 0.7%, 1.3% and 1.2% for HIV, hepatitis B and syphilis. Female sex workers (FSWs) (relative risk [RR] 4.4, P = 0.03) and partners of person living with HIV (RR 25.9, P < 0.001) had a higher risk of being HIV-positive. FSWs had also a greater risk of being syphilis-positive (RR 9.1, P < 0.001).

CONCLUSION

The increase in uptake of HCT services by MARPs is a welcome finding; however, the relatively static trends call for the introduction of community outreach approaches. The critical gateway being provided to MARPs is an 'opportunity' for the expansion of the current service package.

HIV testing and retention in care of infants born to HIV- infected women enrolled in 'Option B+', Thyolo, Malawi

Prevention of mother-to-child transmission 'Option B+' originated in Malawi in 2011 to prevent new infections in infants exposed to the human immunodeficiency virus (HIV). We assessed 12-month programme retention and HIV testing uptake among infants born to HIV-infected mothers from September 2011 to June 2012 in Thyolo District Hospital. Of 513 infants, 368 (71.7%) remained in care at 12 months. Altogether, 412 (80.3%) underwent HIV DNA polymerase chain reaction testing, with 267 (52.0%) tested at 6-12 weeks, and 255 (49.7%) underwent rapid HIV testing, with 144 (28.1%) tested at 12 months. Eighty-eight (17.2%) infants had both tests as scheduled. Measures are needed to improve adherence to national testing protocols.

Management of previously treated tuberculosis patients in Kalutara district, Sri Lanka: how are we faring?

SETTING

District Chest Clinic, Kalutara, Sri Lanka.

OBJECTIVES

To determine the coverage of culture and drug susceptibility testing (CDST), delays in CDST, treatment initiation, obtaining CDST results and treatment outcomes of previously treated tuberculosis (TB) patients.

DESIGN

Retrospective cohort study involving review of records and reports. All previously treated TB patients from January 2008 to June 2013 were included in the study.

RESULTS

Of 160 patients, 126 (79%) samples were sent for CDST; 79 (63%) were culture-positive and no multi-drug-resistant (MDR) TB cases were reported. Respectively 9% and 15% of patients experienced a delay in sending samples (median delay 21 days) and receiving CDST reports (median delay 71 days), while 20% experienced delays in initiating the retreatment regimen (median delay 11.5 days). The cohort recorded an 82% treatment success rate.

CONCLUSION

Of all retreatment patients, only 79% were tested for CDST and there were sizeable delays in sample transportation and treatment initiation. Possible ways forward to strengthen the programme are discussed.

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

Antibiotic use in a district hospital in Kabul, Afghanistan: are we overprescribing?

SETTING

A district hospital in Kabul, Afghanistan, supported by Médecins Sans Frontières (MSF).

OBJECTIVES

To assess antibiotic prescribing practices in the out-patient department in summer (August 2013) and winter (January 2014).

DESIGN

Cross-sectional study, using routinely collected hospital data and using World Health Organization (WHO) defined daily dose (DDD) methodology.

RESULTS

An analysis of 4857 prescriptions (summer) and 4821 prescriptions (winter) showed that respectively 62% and 50% of all out-patients were prescribed at least one antibiotic. Prescriptions without a recorded diagnosis represented a sizeable proportion of all antibiotics prescribed. For upper respiratory tract infections (URTI), dental indications, urinary tract infections (UTI) and diarrhoea, good adherence to dosages recommended in the MSF standard treatment guidelines was observed when measured by DDD. However, certain drugs not indicated in the guidelines were prescribed, such as amoxicillin and metronidazole for UTI and azithromycin for URTI.

CONCLUSION

Rates of antibiotic prescriptions for out-patients in a district hospital in Afghanistan were high, double the WHO recommendation of 30%. While systematic non-adherence to recommended dosages was not observed, inappropriate prescriptions for specific conditions may have occurred. This study suggests that knowledge about context-specific determinants of antibiotic prescribing is a first step towards promoting rational prescribing practices in such settings.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

Burden, characteristics, management and outcomes of HIV-infected patients with Kaposi's sarcoma in Zomba, Malawi

SETTING

Antiretroviral treatment (ART) clinic at Zomba Central Hospital, Malawi.

DESIGN

Retrospective analysis of records (2004-2011) of human immunodeficiency virus (HIV) infected patients with Kaposi's sarcoma (KS).

OBJECTIVES

To determine the number and characteristics of HIV-infected adult patients with KS on ART and vincristine (VCR) therapy and their treatment outcomes.

RESULTS

A total of 545 HIV-infected patients with KS (58% male, median age 33 years) were included in the study. The baseline median CD4 count was 180 cells/µl (interquartile range 111-287). Cumulative outcomes were as follows: 168 (31%) were still alive, 133 (24%) had died, 172 (32%) were lost to follow-up and 71 (13%) had transferred out; 229 had received at least one course of VCR, 171 had received less than one full course and 145 had not received VCR. The survival probability for 229 patients who received at least one course of VCR was 65% at 1 year, 42% at 2 years and 13% by 6 years. Patients who started VCR therapy before or concurrently with ART had a higher risk of death and generally a higher risk of death and loss to follow-up than those who started VCR after ART.

CONCLUSION

Poor outcomes were noted in HIV-infected patients with KS in a programme setting in Malawi. Other treatment interventions, including combination and/or second-line chemotherapy and earlier ART initiation, are needed to reduce morbidity and mortality.

Relationship between education and training activities and tuberculosis case detection in Fiji, 2008-2011

Due to concerns about under-reporting of the tuberculosis (TB) case burden in Fiji, efforts have been put into national training, education and awareness activities in the formal health sector and among village health workers, health volunteers and the community since 2010. There has been an absolute increase in TB registrations, and TB case notification rates during the period of training activities in 2010 (21.3 per 100 000 population) and 2011 (23.6/100 000) were significantly increased compared with TB case notification rates in 2008 (12.4/100 000) and 2009 (14.6/100 000), when no training activities took place (P < 0.01). These findings support the use of ongoing training efforts.

Non-adherence to standard treatment guidelines in a rural paediatric hospital in Sierra Leone

SETTING

A rural paediatric hospital in Bo, Sierra Leone.

OBJECTIVES

To assess the level of adherence to standard treatment guidelines among clinicians prescribing treatment for children admitted with a diagnosis of malaria and/or lower respiratory tract infection (LRTI), and determine the association between (non) adherence and hospital outcomes, given that non-rational use of medicines is a serious global problem.

DESIGN

Secondary analysis of routine programme data.

RESULTS

Data were collected for 865 children admitted with an entry diagnosis of malaria and 690 children with LRTI during the period January to April 2011; some patients were classified in both categories. Non-adherence to guidelines comprised use of non-standard drug regimens, dosage variations, non-standard frequency of administration and treatment duration. Cumulative non-adherence to guidelines for LRTI cases was 86%. For malaria, this involved 12% of patients. Potentially harmful non-adherence was significantly associated with an unfavourable hospital outcome, both for malaria and for LRTI cases.

CONCLUSIONS

Overall non-adherence to standard treatment guidelines by clinicians in a routine hospital setting is very high and influences hospital outcomes. This study advocates for the implementation of routine measures to monitor and improve rational drug use and the quality of clinical care in such hospitals.

Do incentives improve tuberculosis treatment outcomes in the Republic of Moldova?

SETTING

Tuberculosis (TB) health facilities in the Republic of Moldova, where various incentives were provided to TB patients to improve treatment outcomes.

OBJECTIVE

To compare treatment outcomes among new drug-susceptible TB patients registered for treatment before (2008) and after (2011) introduction of incentives.

DESIGN

Retrospective cohort study using data from the national electronic patient database and incentive registers.

RESULTS

Of 2378 patients registered in 2011, 1895 (80%) received incentives (cash, food vouchers, travel reimbursement). Compared to 2008 (no incentives, n = 2492), the patients registered with incentives in 2011 had higher treatment success (88% vs. 79%, P < 0.001) and lower proportions of unsuccessful outcomes: loss to follow-up (5% vs. 10%, P < 0.001), death (5% vs. 6%, P = 0.03) and failure (2% vs. 5%, P < 0.001). In multivariate analysis (log-binomial regression) using the intention-to-treat approach, provision of incentives was independently associated with an overall reduction in unsuccessful outcomes of 50% (RR 0.5, 95%CI 0.45-0.62, P < 0.001), after adjusting for other confounders such as sex, age, education, occupation, residence, homelessness, type of TB and human immunodeficiency virus status.

CONCLUSION

Provision of incentives to TB patients significantly improved treatment success rates and needs to continue. Treatment retention increased, thus potentially preventing drug resistance, a serious problem in the Republic of Moldova.

Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh

SETTING

An urban slum in Kamrangirchar, Bangladesh.

OBJECTIVES

Among children aged 6-59 months seeking medical care from the two Médecins Sans Frontières-supported primary health centres, to determine 1) the prevalence of severe acute malnutrition (SAM) and severe chronic malnutrition (SCM), and 2) the extent of overlap between SAM and SCM.

DESIGN

In a retrospective record review, data were analysed from out-patient registers on age, sex, height, weight and mid-upper arm circumference (MUAC) of children attending for medical care from April to September 2011. SAM was defined as weight for height < -3 Z scores of the median and/or MUAC <115 mm. SCM was defined as height for age < -3 Z scores of the median. World Health Organization growth standards were used as reference.

RESULTS

Data were complete in the records of 7318 (98%) children, of whom 322 (4%) had SAM and 1698 (23%) had SCM. Among the 322 children with SAM, 162 (50%) also had SCM.

CONCLUSION

In an urban Bangladesh slum, SAM and SCM co-exist, with a predominance of SCM. The current national guidelines for severe malnutrition, which focus on identification and management only for SAM, urgently need to be expanded to include SCM if substantial childhood morbidity and mortality are to be reduced.

Characteristics, medical management and outcomes of survivors of sexual gender-based violence, Nairobi, Kenya

SETTING

Médecins Sans Frontières Clinic for sexual gender-based violence (SGBV), Nairobi, Kenya.

OBJECTIVES

Among survivors of SGBV in 2011, to describe demographic characteristics and episodes of sexual violence, medical management, pregnancy and human immunodeficiency virus (HIV) related outcomes.

DESIGN

Retrospective review of clinical records and SGBV register.

RESULTS

Survivors attending the clinic increased from seven in 2007 to 866 in 2011. Of the 866 survivors included, 92% were female, 34% were children and 54% knew the aggressor; 73% of the assaults occurred inside a home and most commonly in the evening or at night. Post-exposure prophylaxis for HIV was given to 536 (94%), prophylaxis for sexually transmitted infections to 731 (96%) and emergency contraception to 358 (83%) eligible patients. Hepatitis B and tetanus toxoid vaccinations were given to 774 survivors, but respectively only 46% and 14% received a second injection. Eight (4.5%) of 174 women who underwent urine pregnancy testing were positive at 1 month. Of 851 survivors HIV-tested at baseline, 96 (11%) were HIV-positive. None of the 220 (29%) HIV-negative individuals who returned for repeat HIV testing after 3 months was positive.

CONCLUSION

Acceptable, good quality SGBV medical care can be provided in large cities of sub-Saharan Africa, although further work is needed to improve follow-up interventions.

Performance of decentralised facilities in tuberculosis case notification and treatment success in Armenia

We assessed the performance of decentralised tuberculosis (TB) out-patient centres in tuberculosis (TB) case notification and treatment success in Armenia. An average threshold case notification of ⩾37/100 000 was seen in centres that had higher numbers of presumptive TB patients, where more TB was diagnosed by in-patient facilities and where TB contacts were examined. The number of doctors and/or TB specialists at centres did not influence case notification. Onsite smear microscopy was significantly associated with a treatment success rate of ⩾85% for new TB patients. Addressing specific characteristics of TB centres associated with lower case notification and treatment success and optimising their location may improve performance.

Characteristics and mortality of neonates in an emergency obstetric and neonatal care facility, rural Burundi

SETTING

A Médecins Sans Frontières emergency obstetric and neonatal care facility specialising as a referral centre for three districts for women with complications during pregnancy or delivery in rural Burundi.

OBJECTIVE

To describe the characteristics and in-facility mortality rates of neonates born in 2011.

DESIGN

Descriptive study involving a retrospective review of routinely collected facility data.

RESULTS

Of 2285 women who delivered, the main complications were prolonged labour 331 (14%), arrested labour 238 (10%), previous uterine intervention 203 (9%), breech 171 (8%) and multiple gestations 150 (7%). There were 175 stillbirths and 2110 live neonates, of whom 515 (24%) were of low birth weight, 963 (46%) were delivered through caesarean section and 267 (13%) required active birth resuscitation. Overall, there were 102 (5%) neonatal deaths. A total of 453 (21%) neonates were admitted to dedicated neonatal special services for sick and low birth weight babies. A high proportion of these neonates were delivered by caesarean section and needed active birth resuscitation. Of 67 (15%) neonatal deaths in special services, 85% were due to conditions linked to low birth weight and birth asphyxia.

CONCLUSION

Among neonates born to women with complications during pregnancy or delivery, in-facility deaths due to low birth weight and birth asphyxia were considerable. Sustained attention is needed to reduce these mortality rates.

Tuberculosis in health care workers in Belarus

SETTING

Tuberculosis (TB), including drug-resistant TB, is a serious problem in Belarus.

OBJECTIVES

To determine the prevalence of TB among health care workers (HCWs) along with patient characteristics, treatment outcomes and drug resistance patterns between 2008 and 2012.

DESIGN

A retrospective national record review.

RESULTS

There were 116 HCWs with TB. Case notification rates were higher among HCWs than in the general population (349 vs. 40/100 000 in 2012). Most HCWs with TB were nurses (n = 46, 40%) or nurse assistants (n = 37, 32%), female (n = 100, 86%) and aged 25-44 years (n = 84, 72%). Most common places of work for HCWs with TB were multidrug-resistant (MDR-) and extensively drug-resistant (XDR-TB) wards (n = 23, 20%), general medical (n = 26, 22%) and non-medical (n = 34, 29%) departments. All HCWs had pulmonary TB, 107 (92%) had new TB and 103 (89%) had negative sputum smears. Of the 38 (33%) with culture and drug susceptibility testing (DST), 28 (74%) had MDR-/XDR-TB. In 109 HCWs evaluated for final treatment outcomes, 97 (89%) were successfully treated, and their results were not affected by DST status.

CONCLUSION

This study highlights the high prevalence of recorded TB in HCWs in TB health facilities in Belarus: there is a need to better understand and rectify this problem.

Multi- and extensively drug-resistant tuberculosis in Latvia: trends, characteristics and treatment outcomes

SETTING

Drug-resistant tuberculosis (TB) is an important public health problem in Latvia.

OBJECTIVE

To document trends, characteristics and treatment outcomes of registered patients with multi-drug-resistant (MDR-) and extensively drug-resistant (XDR-) TB in Latvia from 2000 to 2010.

DESIGN

A retrospective national cohort study.

RESULTS

Of 1779 patients, 1646 (92%) had MDR- and 133 (8%) XDR-TB. Over 11 years, the proportion of XDR-TB among MDR-TB patients increased from 2% to 18%. Compared to MDR-TB patients, those with XDR-TB were significantly more likely to have failed MDR-TB treatment (OR 8.4, 95%CI 4.3-16.2), have human immunodeficiency virus infection (OR 3.2, 95%CI 1.8-5.7), be illegal drug users (OR 5.7, 95%CI 2.6-11.6) or have had contact with MDR-TB patients (OR 1.9, 95%CI 1.3-2.8). Cure rates for XDR-TB were 50%. Compared with MDR-TB patients, those with XDR-TB had a higher risk of treatment failure (29% vs. 8%, respectively, P < 0.001). Unfavourable treatment outcomes were significantly associated with being male; having smear-positive disease; pulmonary cavities; failure, default or relapse after previous MDR-TB treatment; and a history of incarceration.

CONCLUSION

More MDR-TB in Latvia is now also XDR-TB. This study identified several risk factors for XDR-TB and, for unfavourable treatment outcomes, highlighting the importance of early diagnosis and appropriate management of MDR-/XDR-TB.

A four-year nationwide molecular epidemiological study in Estonia: risk factors for tuberculosis transmission

SETTING

Estonia has a high proportion of multidrug-resistant tuberculosis (MDR-TB). It is important to link molecular and epidemiological data to understand TB transmission patterns.

OBJECTIVE

To use 24-locus variable numbers of tandem repeat (VNTR) typing and national TB registry data in Estonia from 2009 to 2012 to identify the distribution of drug resistance patterns, Mycobacterium tuberculosis isolate clustering as an index for recent transmission, socio-demographic and clinical characteristics associated with recent transmission, and the distribution of transmission between index and secondary cases.

DESIGN

A retrospective nationwide cross-sectional study.

RESULTS

Of 912 cases with isolate and patient information, 39.1% of isolates were from the Beijing lineage. Cluster analysis identified 87 clusters encompassing 69.1% of isolates. The largest cluster comprised 178 isolates from the Beijing lineage, of which 92.1% were MDR- or extensively drug-resistant TB (XDR-TB). Factors associated with recent transmission were polyresistant TB, MDR- and XDR-TB, human immunodeficiency virus positivity, Russian ethnicity, non-permanent living situation, alcohol abuse and detention. XDR-TB cases had the highest risk of recent transmission. The majority of transmission cases involved individuals aged 30-39 years.

CONCLUSION

Recent TB transmission in Estonia is high and is particularly associated with MDR- and XDR-TB and the Beijing lineage.

Pattern of primary tuberculosis drug resistance and associated treatment outcomes in Transnistria, Moldova

This cohort study assessed drug susceptibility testing (DST) patterns and associated treatment outcomes from Transnistria, Moldova, from 2009 to 2012. Of 1089 newly registered tuberculosis (TB) patients with available DST results, 556 (51%) had some form of drug resistance, while 369 (34%) had multidrug-resistant TB (MDR-TB). There were four cases of extensively drug-resistant TB. MDR-TB patients had poor treatment success (45%); human immunodeficiency virus positivity and a history of incarceration were associated with an unfavourable treatment outcome. This first study from Trans-nistria shows a high level of drug-resistant TB, which constitutes a major public health problem requiring urgent attention.

Constraints in the diagnosis and treatment of Lassa Fever and the effect on mortality in hospitalized children and women with obstetric conditions in a rural district hospital in Sierra Leone

BACKGROUND

Lassa fever (LF) is an acute viral haemorrhagic infection, endemic in West Africa. Confirmatory diagnosis and treatment (ribavirin) is difficult, expensive, and restricted to specialised hospitals. Among confirmed and suspected LF cases, we report on clinical and laboratory features, timing and administration of ribavirin and the relationship with case fatality.

METHODS

We conducted an audit of patient files of suspected LF cases admitted to a pediatric and obstetric referral hospital in rural Sierra Leone (April 2011 to February 2012).

RESULTS

There were 84 suspected LF cases; 36 (43%) were laboratory-confirmed cases, of whom only 20 (56%) received ribavirin after a median duration of eight days (IQR 314 days) of hospital admission. Of 16 patients who did not receive ribavirin, 14 (87%) died before ribavirin treatment could be commenced. Starting ribavirin within six days of admission was associated with a case fatality of 29% (2/7), while starting ribavirin later than six days was associated with a case fatality of 50% (6/12). Among the 48 suspected LF cases without laboratory confirmation, there were 21 (44%) deaths.

CONCLUSIONS

These findings highlight shortcomings in LF management, including diagnostic and treatment delays. More research and development efforts should be devoted to this 'neglected disease'.

Preventable but neglected: rickets in an informal settlement, Nairobi, Kenya

SETTING

The primary care clinics of Médecins Sans Frontières within the informal settlement of Kibera, Nairobi, Kenya.

OBJECTIVE

To describe the demographic and clinical characteristics of children clinically diagnosed with rickets from September 2012 to October 2013.

DESIGN

Descriptive retrospective case review of diagnosis and treatment course with vitamin D and calcium using routine programme data.

RESULTS

Of the 82 children who met the clinical diagnosis of rickets, 57% were male, with a median age of 12 months and 14 months for females. Children with rickets were found to have ⩽3 hours/week sunlight exposure for 71% of the children and malnutrition in 39%. Clinical findings on presentation revealed gross motor developmental delays in 44%. The loss to follow-up rate during treatment was 40%.

CONCLUSIONS

This study found that rickets is a common clinical presentation among children living in the informal settlement of Kibera and that there are likely multiple factors within that environment contributing to this condition. As rickets is a simply and inexpensively preventable non-communicable disease, we suggest that routine vitamin D supplementation be formally recommended by the World Health Organization for well-child care in Africa, especially in the contexts of informal settlements.

Evaluation of hepatic steatosis in dogs with congenital portosystemic shunts using Oil Red O staining

The aims of this prospective study were to quantify steatosis in dogs with congenital portosystemic shunts (CPS) using a fat-specific stain, to compare the amount of steatosis in different lobes of the liver, and to evaluate intra- and interobserver variability in lipid point counting. Computer-assisted point counting of lipid droplets was undertaken following Oil Red O staining in 21 dogs with congenital portosystemic shunts and 9 control dogs. Dogs with congenital portosystemic shunts had significantly more small lipid droplets (<6 μ) than control dogs (P = .0013 and .0002, respectively). There was no significant difference in steatosis between liver lobes for either control dogs and CPS dogs. Significant differences were seen between observers for the number of large lipid droplets (>9 μ) and lipogranulomas per tissue point (P = .023 and .01, respectively). In conclusion, computer-assisted counting of lipid droplets following Oil Red O staining of liver biopsy samples allows objective measurement and detection of significant differences between dogs with CPS and normal dogs. This method will allow future evaluation of the relationship between different presentations of CPS (anatomy, age, breed) and lipidosis, as well as the impact of hepatic lipidosis on outcomes following surgical shunt attenuation.

Achieving the millennium development goal of reducing maternal mortality in rural Africa: an experience from Burundi

OBJECTIVES

To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality.

METHODS

The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi.

RESULTS

In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100,000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100,000 live births).

CONCLUSION

Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa.

Headache caused by craniospinal pressure dissociation in the Arnold-Chiari-syringomyelia syndrome

Two patients with Arnold-Chiari malformation, associated with syringomyelia, are described. They presented with headache caused by coughing, sneezing and straining. The pathogenesis and diagnosis are discussed. The treatment of this condition consists in a fossa posterior decompression, in some cases followed by a syringoperitoneal or a syringosubarachnoid shunt.

The effect of prolonged exercise and in vivo treatment with ACTH and norepinephrine on plasma cortisol and on the levels of energy metabolites in liver, muscle and blood of the guinea pig (Cavia porcellus)

1. Exercise and in vivo treatment with adrenocorticotrophic hormone (ACTH) showed a marked tendency to increase in vivo plasma cortisol levels in the guinea pig (Cavia porcellus). 2. However, in vivo norepinephrine (NE) treatment did not have any notable effect on plasma cortisol levels. 3. Metabolite levels (glycogen, glycerol and lactate) in liver and plantaris and soleus muscle, and the levels of glucose, glycerol and lactate in blood, were determined in response to the same treatments. 4. A number of statistically significant changes, as well as certain trends, in metabolite levels were observed in response to the treatments and are discussed.

The effect of exercise and in vivo treatment with ACTH and norepinephrine on the lipolytic responsiveness of guinea pig (Cavia porcellus) adipose tissue

1. In adipose slices of the guinea pig (Cavia porcellus), adrenocorticotrophic hormone (ACTH) produced a significantly higher lipolytic response (increased Vmax and decreased Km) as compared to norepinephrine (NE), thus indicating a marked difference with human adipose tissue. 2. Exercise-training caused a significant increase in the affinity of the lipolytic response in adipose tissue towards both ACTH and NE, but had no significant effect on Vmax. 3. Prolonged in vivo treatment with both ACTH and NE significantly decreased the responsiveness (affinity and capacity) of adipose slices towards ACTH. Responsiveness towards NE was much less affected.

Pathogenesis and treatment of delayed post-traumatic syringomyelia

The role of trauma in the pathogenesis of syringomyelia has been known for a long time. Repeated microtraumata have been considered to play a role in triggering the classical syringomyelia on the basis of a congenital predisposition. It has been proven that post-traumatic arachnoiditis can cause cavitation in the spinal cord and probably syringomyelia stricto sensu as well. The delayed appearance of syringomyelia after a severe single spinal trauma resulting in contusion of the spinal cord without the complication of arachnoiditis is a more recent issue, but is now well-known. Delayed syringomyelia after a minor single spinal trauma, with at first complete recovery, is extremely rare, and is probably often disregarded as a diagnosis. Having studied such a case, with complete neuroradiological work-up, we want to draw attention to the pathogenetic aspects and the possibilities for treatment, of which the syringoperitoneal shunt seems to be the most efficient one.

Therapeutic approach of posterior fossa tumours in adults. A retrospective study

The authors present a review of their experience with posterior fossa tumours in adults during a period of 20 years. Symptoms, physical findings, tumour histology, operative treatment and results are reviewed in 109 cases. The value of preoperative normalization of intracranial pressure by insertion of a ventriculo-subcutaneous drainage is discussed.

Lateral-paramedian infratentorial approach in lateral decubitus for pineal tumours

All classical operative approaches for pineal tumours have important disadvantages. A lateral-paramedian infratentorial approach in lateral decubitus is proposed. It has the advantage that one can reach the pineal region by way of a shorter distance and over a lower situated part of the upper cerebellar surface. Lifting of the transverse sinus becomes unnecessary. The venous vessels can be saved and there is no risk for air embolism or pneumocephalus.

Anterior cervical fusion and osteosynthetic stabilization according to Caspar: a prospective study of 41 patients with fractures and/or dislocations of the cervical spine

Between June 1984 and April 1988, 41 patients with severe posttraumatic lesions of the cervical spine between the C2-C3 and the C7-T1 level seen consecutively were treated by an anterior cervical fusion and osteosynthetic stabilization according to Caspar. These patients were prospectively studied. Seven patients had a bilateral facet dislocation, 5 a unilateral facet dislocation, 9 an anterior subluxation, 9 an anterior compression fracture, 5 a hangman's fracture, and 6 a hyperextension injury at a lower cervical level. From a neurological point of view, there were 12 patients with an initial complete transverse lesion and 14 with an incomplete transverse lesion, and the remaining 15 patients did not have any deficit initially. Four patients died during the first 3 months after the operation. In 38 patients good anatomical position was obtained, generally by the intraoperative use of the vertebral distractor of Caspar. In all patients excellent immediate postoperative stability of the spine was obtained, although in 2 patients a second operation was necessary a few days after the first one. Postoperatively all patients were "immobilized" by a soft collar for 3 months. Four patients with an initial complete transverse lesion showed some neurological recovery in the postoperative period, and all patients with an incomplete transverse lesion improved. There were no postoperative neurological disturbances in the group of patients who were neurologically normal from the beginning. The mean postoperative hospitalization time was 13.6 days. These results were compared to the results from the literature, concerning other conservative and operative treatments for posttraumatic lesions of the cervical spine.

[Ambulatory myelography using iohexol (Omnipaque): methods and results]

Outpatient myelography with iohexol (Omnipaque) was performed in 150 patients. Side effects were noted in 28 patients (19%), with only 3 (2%) major complaints. It concerned 2 patients with severe and prolonged headache and one patient with seizures. Side effects were not more frequent in outpatient myelography than in reported series of hospitalized patients. The frequency of side effects was significantly lower with the use of iohexol than in comparable studies with metrizamide. Headache was the most frequent side effect, followed by an increase or exacerbation of ischiatiform pain, nausea and vomiting. Side effects were slightly more frequent in cervical myelography than in lumbar myelography and were not related to underlying pathology. It is concluded that outpatient myelography is feasable for as far as iohexol is used and patient surveillance is carefully organized.

Clinical experience with Tc-99m HM-PAO high resolution SPECT of the brain in patients with cerebrovascular accidents

In order to evaluate the diagnostic contribution of brain SPECT imaging with 99mTc-HMPAO in cerebrovascular disease, we examined 92 stroke cases (144 lesions), 2 hematoma cases and 30 cases with transient neurologic symptoms. Abnormal tracer distribution is visible as zones of either hypoactivity or hyperactivity (border zone hyperemia or luxury perfusion). Remote vascularization changes could also be found (crossed cerebellar diaschisis or ipsilateral cortical perfusion reduction in thalamic or capsula interna lesions). Both X-ray CT and blood flow SPECT have comparable sensitivity in the exploration of cerebral infarction, with detection in, respectively, 89.5% and 87.5% of the lesions. False negative scintitomographic images are frequently recorded in small lacunar infarcts within the basal ganglia and white matter (capsula interna). Some early infarcts and asymmetry of brain perfusion in patients with transient neurologic symptoms are frequently not detected by CT. An additional advantage of blood flow SPECT is its ability to visualize remote blood flow changes and the changing pattern of vascularization of ischemic lesions and their surrounding areas including hyperemia.

The glossopharyngeal neurinoma. Case reports and literature review

Glossopharyngeal neurinomas are rare entities. Only 16 cases have been described so far in the literature. Our experience with 2 cases demonstrates the non-specific and discrete clinical presentation of the ninth nerve neurinoma, but illustrates also some typical radiological aspects, enabling a more precise preoperative diagnosis. Two cases are presented and a survey of the literature is given.

Low grade astrocytoma in children treated by surgery and radiation therapy

Results of treatment of low grade astrocytoma by surgery and postoperative irradiation in 35 children under 15 were retrospectively analysed. The actuarial overall 5 and 10 year survival was 94 and 82 per cent, the actuarial relapse-free survival 87 and 70 per cent, respectively. The male patients fared better, although not significantly, than the females. No significant difference in relapse rate was found between cystic and solid tumors. The cystic processes had a more indolent course, but a fatal outcome was noted in one case (after 21 years). No relapse occurred in totally removed tumors (10 cases), which throws doubt on the need for postoperative irradiation in this subgroup. In the subtotally resected processes (24 cases) radiation therapy seemed to be beneficial, as in 3 of 4 local recurrences geographic misses of tumour remains probably existed. No dose response relationship was apparent. The performance status was severely impaired in 11 per cent (3/27 patients). Growth retardation was observed in 2 patients.