Association of transmission intensity and age with clinical manifestations and case fatality of severe Plasmodium falciparum malaria

Context  There are concerns that malaria control measures such as use of insecticide-treated bed nets, by delaying acquisition of immunity, might result in an increase in the more severe manifestations of malaria. An understanding of the relationships among the level of exposure to Plasmodium falciparum, age, and severity of malaria can provide evidence of whether this is likely. Objective  To describe the clinical manifestations and case fatality of severe P falciparum malaria at varying altitudes resulting in varying levels of transmission. Design, Setting, and Patients  A total of 1984 patients admitted for severe malaria to 10 hospitals serving populations living at levels of transmission varying from very low (altitude >1200 m) to very high (altitude <600 m) in a defined area of northeastern Tanzania, studied prospectively from February 2002 to February 2003. Data were analyzed in a logistic regression model and adjusted for potential clustering within hospitals. Main Outcome Measures  Specific syndromes of severe malaria; mortality. Results  The median age of patients was 1 year in high transmission, 3 years in moderate transmission, and 5 years in low transmission areas. The odds of severe malarial anemia (hemoglobin <5 g/dL) peaked at 1 year of age at high transmission and at 2 years at moderate and low transmission intensities and then decreased with increasing age (P = .002). Odds were highest in infants (0-1 year: referent; 2-4 years: odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72-0.96), 5 to <15 years: OR, 0.44; 95% CI, 0.27-0.72; 15 years: OR, 0.44; 95% CI, 0.27-0.73; P<.001) and high transmission intensity areas (altitude <600 m: referent; 600 m to 1200 m: OR, 0.55; 95% CI, 0.35-0.84; >1200 m: OR, 0.55; 95% CI, 0.26-1.15; P for trend = .03). The odds of cerebral malaria were significantly higher in low transmission intensity areas (altitude of residence <600 m: referent; 600 m to 1200 m: OR, 3.17; 95% CI, 1.32-7.60; >1200 m: OR, 3.76; 95% CI, 1.96-7.18; P for trend = .003) and with age 5 years and older (0-1 year: referent; 2-4 years: OR, 1.57; 95% CI, 0.82-2.99; 5 to <15 years: OR, 6.07; 95% CI, 2.98-12.38; 15 years: OR, 6.24; 95% CI, 3.47-11.21; P<.001). The overall case-fatality rate of 7% (139 deaths) was similar at high and moderate levels of transmission but increased to 13% in low transmission areas (P = .03), an increase explained by the increase in the proportion of cases with cerebral malaria. Conclusions  Age and level of exposure independently influence the clinical presentation of severe malaria. Our study suggests that an increase in the proportion of cases with more fatal manifestations of severe malaria is likely to occur only after transmission has been reduced to low levels where the overall incidence is likely to be low.      

Neonatal morbidity and mortality in a Tanzanian tertiary care referral hospital

In developing countries, neonatal mortality accounts for 50-70% of infant mortality. The purpose of this study was to describe morbidity and mortality patterns, with a focus on neonatal infections, in a Tanzanian special care baby unit (SCBU). During a 3-month period, 246 consecutive admissions to the SCBU at Kilimanjaro Christian Medical Centre were audited. Prematurity, low birthweight and suspected infection accounted for 61% of all admissions. The overall mortality rate was 19%, but varied considerably according to gestational age, birthweight and diagnosis. Thirty-one neonates (two-thirds of all deaths) died during the 1st 24 hours of life. Of 27 infants admitted on grounds of perinatal asphyxia, 11 (41%) died, and, of 19 infants with a gestational age <31 weeks, 13 (68%) died. More than two-thirds of all infants were treated with antibiotics. Septicaemia confirmed by blood culture was found in 16 cases. The susceptibility pattern of bacterial isolates did not indicate high rates of resistance to commonly used antibacterial agents. A reduction in the number of preterm deliveries and improved perinatal care to avoid and treat perinatal asphyxia would be the two most important measures in reducing neonatal mortality in this setting.     

Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study

Background

Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+?at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context.

Methods

An explanatory sequential mixed-method study (a) reviewed records of all clients (n?=?11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n?=?10) and Care and Treatment Centers (CTCs) (n?=?8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n?=?8) and in-depth qualitative interviews with cohort members (n?=?10) and health care providers (n?=?20).

Results

More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p?<?0.001). Mobile site clients were more likely to be younger and male (p?<?0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p?<?0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs).

Conclusions

Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less “linkage-ready”. Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.

     

Exploring an Emerging Measurement Issue in Older Adult Maltreatment: Exploitation of Older Adults’ Residences

ABSTRACT

Despite nationwide housing challenges that might lead to the exploitation of older adults’ housing resources, exploitation of older adults’ residences has not been a focus of measurement in the rapidly developing field of elder abuse and neglect. Rather, measures of older adult abuse and exploitation used in the research literature emphasize specific property, money, or resources being taken. Two composites are used to illustrate exploitation of older adults’ residences by trusted others on whom the older adults depended with potentially serious implications for environmental safety and ultimately the older adults’ housing stability. As part of a larger study on older adult maltreatment, police reports were coded for abuse and financial exploitation as well as misuse of the older adult’s residence that threatened the older adult’s housing security and/or exerted control over the older adult. Nearly one in ten (9.2%) police reports involving older adult victims and known/trusted perpetrators described exploitation of residences. Residence exploitation was separable from financial exploitation and less likely to co-occur with neglect. Considering the importance of housing stability to older adult well-being, consequences of maltreatment by a known/trusted other, and a national housing crisis, we propose that exploitation of older adults’ residences warrants further measurement and practice attention. Findings are relevant to advancing theory in older adult maltreatment (e.g., application of white-collar crime versus betrayal trauma and family violence theories).     

Clinical assessment and treatment in paediatric wards in the north-east of the United Republic of Tanzania

OBJECTIVE: We assessed paediatric care in the 13 public hospitals in the north-east of the United Republic of Tanzania to determine if diagnoses and treatments were consistent with current guidelines for care. METHODS: Data were collected over a five-day period in each site where paediatric outpatient consultations were observed, and a record of care was extracted from the case notes of children on the paediatric ward. Additional data were collected from inspection of ward supplies and hospital reports. FINDINGS: Of 1181 outpatient consultations, basic clinical signs were often not checked; e.g. of 895 children with a history of fever, temperature was measured in 57%, and of 657 of children with cough or dyspnoea only 57 (9%) were examined for respiratory rate. Among 509 inpatients weight was recorded in the case notes in 250 (49%), respiratory rate in 54 (11%) and mental state in 47 (9%). Of 206 malaria diagnoses, 123 (60%) were with a negative or absent slide result, and of these 44 (36%) were treated with quinine only. Malnutrition was diagnosed in 1% of children admitted while recalculation of nutritional Z-scores suggested that between 5% and 10% had severe acute malnutrition; appropriate feeds were not present in any of the hospitals. A diagnosis of HIV-AIDS was made in only two cases while approximately 5% children admitted were expected to be infected with HIV in this area. CONCLUSION: Clinical assessment of children admitted to paediatric wards is disturbingly poor and associated with missed diagnoses and inappropriate treatments. Improved assessment and records are essential to initiate change, but achieving this will be a challenging task.