Assessment of Pediatric Surgery Capacity at Government Hospitals in Sierra Leone

Background

Traditionally, efforts to reduce child mortality in low- and middle-income countries (LMICs) have focused on infectious diseases. However, surgical care is increasingly seen as an important component of primary health care. To understand the baseline surgical capacity in LMICs, a number of studies have recently been published, but none has focused on pediatric surgery.

Methods

The Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) survey was used to collect surgical capacity data from government hospitals in Sierra Leone. The data were analyzed specifically to identify baseline needs for pediatric surgery.

Results

Nine hospitals were assessed, and all had a functioning laboratory to test blood and urine and were capable of undertaking resuscitation, suturing, wound débridement, incision and drainage of an abscess, appendectomy, and male circumcision. However, in only 67?% could a pediatric hernia repair be performed, and in none were more complex procedures such as cleft lip and clubfoot repairs performed. Fewer than 50?% of facilities had sufficient gloves, nasogastric tubes, intravenous cannulas, syringes, needles, sutures, urinary catheters, infusion sets, anesthesia machines, or compressed oxygen.

Conclusions

Using the standard PIPES tool, we found severe deficiencies in the pediatric surgical capacity at government hospitals in Sierra Leone. However, a pediatric-specific tool is required to understand more accurately the pediatric surgical situation.     

Bacteraemia in homozygous sickle cell disease in Africa: is pneumococcal prophylaxis justified?

BACKGROUND: The high frequency of Streptococcus pneumoniae as a cause of bacteraemia in homozygous sickle cell (SS) disease and its effective prevention has led to the routine use of pneumococcal prophylaxis in developed countries. The reported infrequency of this organism as a cause of bacteraemia in SS disease in Africa raises questions on the epidemiology of bacterial infection and on the need for pneumococcal prophylaxis in that continent. METHODS: A study of blood cultures in 155 Ugandan children (165 episodes) with SS disease and axillary temperatures of > or =38 degrees C, attending the University Teaching Hospital in Kampala (Uganda, East Africa). RESULTS: Positive blood cultures, obtained in 47/165 episodes, showed Staphylococcus aureus in 28 (60%) samples, Haemophilus influenzae in 9 (19%), Staphylococcus epidermidis in 4 (9%), and single cases of Streptococcus viridans, Escherichia coli and an unidentified Gram negative rod. Streptococcus pneumoniae was identified in only 3 (6%) episode. CONCLUSION: The infrequent isolation of Streptococcus pneumoniae from febrile children with SS disease in this study and in four other studies from Nigeria raises questions on a different spectrum of bacterial causes for bacteraemia in malarial areas. There are several possible explanations for this finding, but the data cast sufficient doubt on the case for pneumococcal prophylaxis for a controlled trial on its effectiveness in that environment to seem justified. These data are necessary to determine its role in African children and to provide the evidence base for healthcare authorities in equatorial Africa.     

TRACnet: A National Phone-based and Web-based Tool for the Timely Integrated Disease Surveillance and Response in Rwanda

Objective

(1) To describe the implementation of the electronic system for integrated disease surveillance in Rwanda. (2) To present the sensitivity and specificity of the electronic reporting system to detect potential outbreaks

Introduction

In Rwanda, communicable diseases are the mostly predominant representing 90% of all reported medical consultations in health centers. The country has often faced epidemics including emerging and re-emerging infectious diseases. To enhance its preparedness to identify and respond to outbreaks and prevent epidemics, the Government of Rwanda has developed and deployed an electronic Integrated Disease Surveillance and Response (eIDSR) working with Voxiva with funding from the U.S. Centers for Disease Control and Prevention(CDC).

Methods

The eIDSR is built on Rwanda’s existing national phone and web-based HIV-reporting system, “TRACnet” that has been operating nationwide since 2004. Data is collected for 23 communicable diseases under surveillance in Rwanda categorized into immediately and weekly reportable. If a lab test is required, the sample is taken and sent to laboratory for testing. Immediate, Weekly, Lab request and lab results forms are completed before submitting data in the system. Data is entered using phone or web based application and is stored in the central database.

Results

The design of eIDSR module was completed in November 2011. As of September 2012, 252 out of 457 health facilities in Rwanda have been trained and are using the electronic system (over 50% of coverage); the national roll out is still going on with complete coverage planned for December 2012. The system sends SMS reminders for due and overdue reports. The timeliness and completeness of reporting are 98% and 100% respectively. Notifications are sent to the concerned personnel when the threshold for outbreak detection is reached. When lab results are available and entered in the system, the results are automatically communicated to the health centers originating samples. Data is automatically summarized in predefined tables, graphs, dashboards and maps.As of September 3rd, 2012, a total of 5813 reports including 1325 immediate reports and 4488 weekly reports were submitted electronically. Out of 1325 immediate reports submitted, 406 potential outbreaks were detected and immediately notified and 7 of them were confirmed for cholera, rubella, Influenza-like illness (H1N1), measles and food poisoning. From these data, the eIDSR system shows a sensitivity of 100% and a specificity of 70% for outbreak detection. The early notification of probable outbreaks stimulated the early investigations and the quick response to outbreaks within the country and across the borders.

Conclusions

The electronic disease surveillance system has improved timeliness and completeness of reporting and extremely supports early detection and notification of outbreaks for timely response. This system should be a model for the East African region as it has demonstrated advantages in the cross-border disease surveillance.     

Antiretroviral treatment uptake and attrition among HIV-positive patients with tuberculosis in Kibera, Kenya

Using data of human immunodeficiency virus-positive patients with tuberculosis from three primary care clinics in Kibera slums, Nairobi, Kenya, we report on the proportion that started antiretroviral treatment (ART) and attrition (deaths, lost to follow-up and stopped treatment) before and while on ART. Of 427 ART eligible patients, enrolled between January 2004 and December 2008, 70% started ART, 19% were lost to attrition and 11% had not initiated ART. Of those who started ART, 14% were lost to attrition, making a cumulative pre-ART and ART attrition of 33%. ART uptake among patients with TB was relatively good, but programme attrition was high and needs urgent addressing.     

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals,Uganda

Setting:

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases.

Objective:

To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes.

Design:

A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010.

Results:

The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73).

Conclusion:

Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.