District Referral Hospital Research Articles

Midwife-led obstetric triage to increase providers’ knowledge and improve timeliness of care: A pre and posttest design

BackgroundResearch in low- and middle-income countries has shown that maternal mortality is directly related to inadequate or absent obstetric (OB) triage systems. Standard triage systems and knowledge on triaging for obstetric emergencies are often absent or lacking in most healthcare systems in Liberia. ObjectiveThe objective of this research was to address the third delay defined as receiving adequate, quality care when a facility is reached by increasing knowledge through the establishment of a midwife-led, hospital-based OB triage system to stratify care based on risk and imminence of birth and to improve timely assessment at two district referral hospitals. MethodsA quasi-experimental study design using a pre/post survey was employed for a midwife-led OB triage training course. Using a train-the-trainer model, five midwives were trained as champions, who in turn trained an additional 62 providers. Test results were analyzed with the R statistical software using paired sample t-test and descriptive statistics. ResultsPretest results revealed a knowledge and practice gap among OB providers on key components of the standard triage package. However, post-test mean scores were significantly higher (M = 79.6, SD = 2.32) than pre-test mean scores (M = 59.0, SD = 2.30) for participants following a 2-day training (p = <0.001). DiscussionFollowing a structured OB triage training, participants showed significant improvement in post-test OB triage scores. ConclusionStandard OB triage protocols incorporated into the policies and procedures of obstetric wards have the potential to improve knowledge and practice, addressing the third delay and reducing preventable, obstetrics-related deaths.

Improving Malaria Case Management and Referral Relationships at the Primary Care Level in Ghana: Evaluation of a Quality Assurance Internship.

In Ghana, Community-based Health Planning and Services (CHPS) compounds managed by trained nurses and midwives called community health officers (CHOs) play a major role in malaria service delivery. With heavy administrative burdens and minimal training in providing patient care, particularly for febrile illnesses, including malaria, CHOs struggle to comply with the World Health Organization's test, treat, and track initiative guidelines and appropriate referral practices. A clinical training and mentorship program was implemented for CHOs to prevent and manage uncomplicated malaria and offer appropriate pre-referral treatment and referrals to district hospitals. Medical officers, pharmacists, midwives, health information officers, and medical laboratory scientists at 52 district referral hospitals were trained as mentors; CHOs from 520 poorly performing CHPS compounds underwent a 5-day internship at their assigned district referral hospital to improve knowledge and clinical skills for malaria case management. Three months later, mentors conducted post-training mentoring visits to assess knowledge and skill retention and provide ongoing on-the-job guidance. Significant percentage-point increases were observed immediately post-internship for history taking (+12.0, 95% confidence interval [CI]=8.3, 15.1; P<.001); fever assessment (+24.9, 95% CI=20.9, 29.3; P<.001); severe malaria assessment and referral (+32.0, 95% CI=28.2, 35.8; P<.001); and knowledge assessment (+15.8, 95% CI=10.0, 21.3; P<.001). Three months later, a third assessment revealed these gains were largely maintained. Analysis of national health management information system data showed statistically significant improvements in testing, treatment, and referral indicators at intervention CHPS compounds after the intervention that were not observed in comparison CHPS compounds. This training and mentorship approach offers a replicable model to build primary care provider competencies in malaria prevention and management and demonstrates how developing relationships between primary care and first-level referral facilities benefits both providers and clients. More methodologically rigorous studies are needed to measure the impact of this approach.

Prevalence and determinants of non-communicable diseases including depression among HIV patients on antiretroviral therapy in Dar es Salaam, Tanzania.

People living with HIV/AIDS (PLHA) are experiencing growing co-morbidities due to an increase in life expectancy and the use of long-term antiretroviral therapy (ART). The lack of integrated non-communicable diseases (NCDs) screening and management at the HIV care and treatment centres (CTCs) make it difficult to determine the trends of NCD co-morbidity among patients with HIV. This study aimed to assess the burden and determinants of common NCDs, including depression among patients with HIV. Analytical cross-sectional study of 1318 HIV patients enrolled using systematic random sampling conducted from April to November 2020. Five large CTCs in district referral hospitals were selected representing the five districts of Dar es Salaam including Mwananyamala, Temeke, and Amana regional referral hospitals and Sinza and Vijibweni hospitals. The study population consisted of adult PLHA aged 18 years and above. The primary outcome measure was the prevalence of NCDs among HIV patients. Observation of actual NCD medications or their purchase receipts or booked NCD clinic appointments that PLHA had during the study period was used to verify the reported presence of NCDs. The secondary outcome measure was the prevalence of probable depression among PLHA. The locally validated Swahili Patient Health Questionnaire (PHQ-9) was used to screen for depressive symptom severity. A logistic regression model was used to identify factors associated with common NCDs and those associated with probable depression. Potential risk factors that were statistically significant at a P-value of 0.2 or less in univariable analysis were included as potential confounders in multivariable models. The median age of participants was 42 (IQR 35-49) years, with 32.7% in the 36-45 years age group. The majority of patients were women (69%). Most (80.5%) had achieved HIV viral (VL) suppression (a serum HIV VL of <1000 copies/ml). Overall, 14.3% of self-reported an NCD with evidence of their current medication for the NCD from receipts for medication purchased and appointments from NCD clinics they attended. In the multivariable analyses, higher odds of NCDs were in older patients (>45 years) and those with a weight above 75 kg (P < 0.05). Male patients had 51% reduced odds of NCDs (aOR 0.49; 95% CI: 0.32-0.74) than females (P < 0.001). Probable depression prevalence was 11.8%, and depressed patients had more than twice the odds of having NCDs than those without depression (aOR 2.26; 95% CI: 1.45-3.51; P < 0.001). This study determined co-existing previously diagnosed NCDs among PLHA accessing care and high levels of depressive symptom severity. We recommend additional research on the feasibility, acceptability, and cost implications of screening and treating NCDs on HIV care platforms to provide evidence for Tanzania's integrated HIV/NCD care model.

Hypoxemia, hypoglycemia and IMCI danger signs in pediatric outpatients in Malawi.

Hypoxemia and hypoglycemia are known risks for mortality in children in low-income settings. Routine screening with pulse oximetry and blood glucose assessments for outpatients could assist in early identification of high-risk children. We assessed the prevalence of hypoglycemia and hypoxemia, and the overlap with Integrated Management of Childhood Illness (IMCI) general danger signs, among children seeking outpatient care in Malawi. A cross-sectional study was conducted at 14 government primary care facilities, four rural hospitals and one district referral hospital in Mchinji district, Malawi from August 2019-April 2020. All children aged 0-12 years seeking care with an acute illness were assessed on one day per month in each facility. Study research assistants measured oxygen saturation using Lifebox LB-01 pulse oximeter and blood glucose was assessed with AccuCheck Aviva glucometers. World Health Organization definitions were used for severe hypoglycemia (<2.5mmol/l) and hypoxemia (SpO2 <90%). Moderate hypoglycemia (2.5-4.0mmol/l) and hypoxemia (SpO2 90-93%) were also calculated and prevalence levels compared between those with and without IMCI danger signs using chi2 tests. In total 2,943 children were enrolled, with a median age of 41 (range: 0-144) months. The prevalence of severe hypoxemia was 0.6% and moderate hypoxemia 5.4%. Severe hypoglycemia was present in 0.1% of children and moderate hypoglycemia in 11.1%. IMCI general danger signs were present in 29.3% of children. All severely hypoglycemic children presented with an IMCI danger sign (p <0.001), but only 23.5% of the severely hypoxemic and 31.7% of the moderately hypoxemic children. We conclude that while the prevalence of severe hypoxemia and hypoglycemia were low, moderate levels were not uncommon and could potentially be useful as an objective tool to determine referral needs. IMCI danger signs identified hypoglycemic children, but results highlight the challenge to detect hypoxemia. Future studies should explore case management strategies for moderate hypoxemia and hypoglycemia.

Ultrasound at labour triage in eastern Uganda: A mixed methods study of patient perceptions of care and providers' implementation experience.

In settings where antenatal ultrasound is not offered routinely, ultrasound use when a woman first presents to the maternity ward for labour (i.e., triage) may be beneficial. This study investigated patients’ perceptions of care and providers’ experience with ultrasound implementation during labour triage at a district referral hospital (DH) and three primary health centers (HC) in eastern Uganda. This was a mixed methods study comprising questionnaires administered to women and key informant interviews among midwives pre- and post-ultrasound introduction. Bivariate analyses were conducted using chi-square tests. Qualitative themes were categorized as (1) workflow integration; (2) impact on clinical processes; (3) patient response to ultrasound; and (4) implementation barriers. A total of 731 and 815 women completed questionnaires from the HCs and DH, respectively. At the HC-level, triage quality of care, satisfaction and recommendation ratings increased with implementation of ultrasound. In contrast, satisfaction and recommendation ratings did not differ upon ultrasound introduction at the DH, whereas perceived triage quality of care increased. Most participants noted a perceived improvement in midwives’ experience and knowledge upon introduction of ultrasound. Women who underwent a scan also reported diverse feelings, such as fear or worry about their delivery, fear of harm due to the ultrasound, or relief after knowing the baby’s condition. For the midwives’ perspective (n = 14), respondents noted that ultrasound led to more accurate diagnoses (e.g., fetal position, heart rate, multiple gestation) and improved decision-making. However, they noted health system barriers to ultrasound implementation, such as increased workload, not enough ultrasound-trained providers, and irregular electricity. While triage ultrasound in this context was seen as beneficial to mothers and useful in providers’ clinical assessments, further investigation around provider-patient communication, system-level challenges, and fears or misconceptions among women are needed.

High Prevalence of Low Birth Weight Babies Born to Pregnant Women Referred to a District Hospital in Rural Zambia.

Low birthweight (LBW) is a significant public health problem in sub-Saharan Africa and LBW in rural Zambia is high. Our study explored the prevalence of LBW for newborns whose mothers were referred from a rural health center to a district referral hospital in Lundazi, Zambia. A five-month retrospective record review of Ministry of Health data was performed to examine birthweight characteristics of a convenience sample of newborns from ten facilities referring to one district hospital (n = 234). Among all cases, 21% (n = 49) of newborns were LBW. For LBW newborns, 73% (n = 36) were preterm with mothers having a pregnancy duration of less than 37weeks. Newborns whose mothers experienced twin pregnancies (p = .021) and prolonged labor (p = .033) were more often LBW. However, regression models demonstrated no difference among newborns with and without LBW for prolonged labor (p = .344) and twin pregnancies (p = .324) when controlling for variables that could interact with the maternal-newborn delivery outcomes. for Practice Healthcare providers and policy makers need to address the short and long-term effects of LBW throughout the lifecycle in rural Zambia. More maternal-newborn health research is needed to understand the underlying socioeconomic, social, and cultural determinants influencing LBW in rural Zambia.

Decentralised hepatitis C testing and treatment in rural Cambodia: evaluation of a simplified service model integrated in an existing public health system

Direct-acting antiviral treatment for hepatitis C virus (HCV) has provided the opportunity for simplified models of care delivered in decentralised settings by non-specialist clinical personnel. However, in low-income and middle-income countries, increasing overall access to HCV care remains an ongoing issue, particularly for populations outside of urban centres. We therefore aimed to implement a simplified model of HCV care via decentralised health services within a rural health operational district in Battambang province, Cambodia. The study cohort included adult residents (≥18 years) of the health operational district of Moung Russei who were voluntarily screened at 13 local health centres. Serology testing was done by a rapid diagnostic test using SD Bioline HCV (SD Bioline HCV, Standard Diagnostics, South Korea) with capillary blood. HCV viral load testing was done by GeneXpert (Cepheid, Sunnyvale, CA, USA). Viraemic patients (HCV viral load ≥10 IU/mL) received pretreatment assessment by a general physician and minimal treatment evaluation tests at the health operational district referral hospital. Viraemic patients who did not have additional complications received all HCV care follow-up at the local health centres, provided by nursing staff, and patients who had decompensated cirrhosis, previously treated with a direct-acting antiviral, HBV co-infection, or other comorbidities requiring observation continued receiving care at the referral hospital with a general physician. Patients deemed eligible for treatment were prescribed oral sofosbuvir (400 mg) and daclatasvir (60 mg) once a day for 12 weeks, or 24 weeks for patients with decompensated cirrhosis or those previously treated with a direct-acting antiviral. HCV cure was defined as sustained virological response at 12 weeks after treatment (HCV viral load <10 IU/mL). Patients were assessed for serious and non-serious adverse events at any time between treatment initiation and 12 weeks post-treatment testing. Between March 12, 2018, and Jan 18, 2019, 10 425 residents (ie, 7·6% of the estimated 136 571 adults in the health operational district of Moung Russei) were screened. Of those patients screened, the median age was 44 years (IQR 31-55) and 778 (7·5%) were HCV-antibody positive. 761 (97·8%) of 778 antibody-positive patients received HCV viral load testing, and 540 (71·0%) of those tested were HCV viraemic. Among these 540 patients, linkage to treatment and follow-up care was high, with 533 (98·7%) attending a baseline consultation at the HCV clinic, of whom 530 (99·4%) initiated treatment. 485 (91·5%) of 530 patients who initiated treatment received follow-up at a health centre and 45 (8·5%) were followed up at the referral hospital. Of the 530 patients who initiated direct-acting antiviral therapy, 515 (97·2%) completed treatment. Subsequently, 466 (90·5%) of 515 patients completed follow-up, and 459 (98·5%) of 466 achieved a sustained virological response at 12 weeks after treatment. Two (0·4%) adverse events (fatigue [n=1] and stomach upset [n=1]) and five (0·9%) serious adverse events (infection [n=2], cardiovascular disease [n=1], and panic attack [n=1], with data missing for one of the causes of serious adverse events) were reported among patients who initiated treatment. All serious adverse events were deemed to be unrelated to therapy. This pilot project showed that a highly simplified, decentralised model of HCV care can be integrated within a rural public health system in a low-income or middle-income country, while maintaining high patient retention, treatment efficacy, and safety. The project delivered care via accessible, decentralised primary health centres, using non-specialist clinical staff, thereby enhancing the efficient use of limited resources and maximising the potential to test and treat individuals living with HCV infection. Médecins Sans Frontières.

English

In rural Zambia, pregnant mothers are referred from rural primary health facilities designed to provide Basic Emergency Obstetric and Newborn Care (BEmONC) to district hospitals where Comprehensive Emergency Obstetric and Newborn Care (CEmONC) can be provided when needed. Maternity waiting homes (MWH) are residential dwellings where mothers can await delivery and may offer a possible early referral source to CEmONC, ultimately serving as an intervention to improve maternal-newborn delivery outcomes. This case series study aimed to advance an understanding of maternal-newborn delivery outcomes for mothers referred from health facilities with and without MWHs to one district referral hospital. A retrospective medical record review of district-level data was performed to compare maternal-newborn delivery outcomes for cases referred from five BEmONC health facilities with and five without MWHs to a CEmONC district referral hospital. Information about MWH use was not recorded in the delivery register, and is unknown. Among all cases (n = 234) referred to a district hospital from facilities with and without MWHs, referrals were more likely to come from facilities with MWHs. Most were referred from facilities more than 12km from the district referral hospital. There were no statistically significant differences in newborn delivery outcomes for cases referred from MWH and non-MWH facilities. More cases with prolonged labor were referred from facilities associated with a MWH than without a MWH (37.3 vs. 23.9%). Access to a MWH may have brought mothers closer to a facility where prolonged labor was recognized and emergency referral was made for obstetric management.&nbsp; Key words: Newborn health, maternal health, pregnancy complications, delivery outcomes, Zambia. &nbsp

Reducing mortality from severe malaria in Sierra Leonean children by applying the World Health Organization's standard malarial protocol with additional sublingual glucose: A continuous quality improvement report

ObjectivesTo reduce childhood mortality from severe malaria by implementing the World Health Organization's standardized malarial treatment protocol. DesignObservational study comparing the mortality rate from malaria before and after the intervention. SettingInpatient pediatric ward in a district referral hospital of Sierra Leone. ParticipantsA total of 1298 pediatric patients (ages 0-13 years, male and female) received the intervention, representing 100% of the pediatric patients admitted with severe malaria during the dates of implementation (there were no exclusion criteria). InterventionsWe implemented the World Health Organization's standardized malarial protocol on September 30, 2015. Based on monthly run reports of mortality and root cause analysis, we adapted the malaria protocol by adding sublingual glucose as a treatment to target hypoglycemia complications in March 2016. Main Outcome MeasuresThe primary outcome was a change in monthly percent mortality from severe malaria, and the secondary outcome was the percent of mortality attributed to hypoglycemia. ResultsThe monthly average percent mortality from severe malaria dropped from 9% to 3.6% after the intervention, which was borderline statistically significant (p 0.06, CI 95% 1.5 to 5.6). The secondary outcome, percent of malarial deaths attributable to hypoglycemia via chart reviews, dropped from 83% to 44% across the study period. There was an increase in the average number of admissions for severe malaria from 71 to 153 children per month in the second half of the year (range from 49-212 per month). ConclusionImplementing the WHO malaria treatment protocol with bedside tracking of protocol steps reduced malaria mortality and improved our ward's efficiency without adding any human or medical resources.

World Cancer Day As a Platform for Advocacy, Stakeholder Mobilization and Awareness Creation: The Experience of Uganda Cancer Society

Background: World Cancer Day (WCD) provides a platform to raise awareness. This year Uganda's commemoration was held at the Parliamentary grounds. Aim: To bring together Uganda's stakeholders through an inclusion approach to advocate for, share information and raise awareness on cancer while recognizing efforts made and appreciating challenges faced in the fight against the epidemic. Strategy: Partnership building was key. Partners involved were; Uganda Cancer Society (UCS), Uganda Cancer Institute (UCI), Ministry of Health, World Health Organization, media, Uganda Corporate League, interreligious council, Kampala Capital City Authority, Parliament of Uganda, Uganda Police and UCS member organizations. Program process: A committee was set up and a concept developed adopting the tri-process approach; “Before - During - After” for implementation of activities. Outcomes: The digital campaign was launched using the signs for change and the #WeCanICanUg. There was high media coverage; 3 major national stations Urban TV, NBS TV and NTV UG, one regional station-CGTN Africa, as well as online platforms such as; WHO Africa Web site, UICC World Cancer Day impact report, the Grape Vine, Chimp reports, and more than 5 YouTube media uploads as per our monitoring and surveillance efforts on reach and impact. The lighting of the Queen's way clock tower attracted many passersby and media coverage. In addition there was awareness creation in select churches (6) and mosques (2) on 4th and 2nd February respectively. The WCD ceremony was attended by over 400 guests and officiated by the Speaker of Parliament who doubled as chief walker. The 7.3 km match past attracted involvement of the community along the way. The Speaker called upon the government through Ministry of Health to inject more money into training of more cancer specialists to work on cancer patients. She also stated the need to have cancer services moved closer than just the regional centers but to every district referral hospital for cancer screening and cancer treatment. She pledged Parliament's unconditional support to work with civil society in the cancer fight. The Minister of Health committed to the full operationalization of regional cancer centers by 2019. She applauded the role of civil society through Uganda Cancer Society on the advocacy efforts stating that they had already started yielding good results . The event ended with the corporate league football competitions which were aimed at promoting healthy lifestyles through physical exercise. Notably was the match between the Parliamentary team and the UCI team. The winner was given a trophy marked WCD 2018. What was learned: The role of civil society through umbrella bodies like UCS plays a crucial role in cancer control as seen during through planning, mobilization, partnership building and execution of WCD activities. Creativity and innovation is key in generating stakeholder and public interest in cancer control activities like WCD.

Outbreak of Wilderness/Backcountry/Travelers’ Diarrhea at a Himalayan Base Camp at 4000 m/13,125 ft

Introduction: Wilderness or backcountry diarrhea is a type of travelers’ diarrhea commonly caused by Cryptosporidium and Giardia, which can survive freezing temperatures. Campsites pose additional risks worldwide, irrespective of developing or developed regions, due to inadequate hygiene. Methods: In a first of its kind, an outbreak of wilderness diarrhea at a semi-permanent Himalayan Base Camp at 4000 m/13,125 ft in Uttarkashi, India, was investigated and managed by empirical antimicrobials. Return of normal bowel function was considered as primary outcome, and return to routine training at Base Camp was considered secondary outcome. Results: Sixty-two personnel presented with wilderness diarrhea of 5.58 days mean duration with onset after mean stay of 10.26 days, despite provisions for adequate camp hygiene and sanitation. Both primary and secondary outcomes were reached by all except three students who were evacuated on foot to the district referral hospital 56 km downhill from Base Camp. Hygiene was compromised due to cold weather/water. Epidemiological surveillance was not contributory. Conclusion: Wilderness diarrhea can present in outbreak proportions from formerly safe water sources due to variable microbial contamination. On-site diagnostics and management are required to control outbreaks of wilderness diarrhea. Traveler risk management strategies and traveler awareness/education can be a targeted mandatory intervention to enhance preparedness and resilience capital in outdoor and mountain environments.

Roles of the eye care workforce for task sharing in management of diabetic retinopathy in Cambodia.

To identify the current roles of eye and health care workers in eye care delivery and investigate their potential roles in screening and detection for management of diabetic retinopathy (DR) through task sharing. Purposive sampling of 24 participants including health administrators, members from non-government organizations and all available eye care workers in Takeo province were recruited. This cross sectional mixed method study comprised a survey and in-depth interviews. Data were collected from medical records at Caritas Takeo Eye Hospital (CTEH) and Kiri Vong District Referral Hospital Vision Centre, and a survey and interviews with participants were done to explore the potential roles for task sharing in DR management. Qualitative data were transcribed into a text program and then entered into N-Vivo (version 10) software for data management and analysis. From 2009 to 2012, a total of 105 178 patients were examined and 14 030 eye surgeries were performed in CTEH by three ophthalmologists supported by ophthalmic nurses in operating and eye examination for patients. Between January 2011 and September 2012, 151 patients (72 males) with retinal pathology including 125 (83%) with DR visited CTEH. In addition 170 patients with diabetes were referred to CTEH for eye examinations from Mo Po Tsyo screening programs for people with diabetes. Factors favouring task sharing included high demand for eye care services and scarcity of ophthalmologists. Task sharing and team work for eye care services is functional. Participants favor the potential role of ophthalmic nurses in screening for DR through task sharing.

Re-Emergence of Tetanus in a District Referral Hospital

Tetanus is an acute, potentially fatal disease caused by Clostridium tetani. It is characterized by generalized, painful spasms and rigidity of skeletal muscles. We present two fatal cases and discuss the potential causes that lead to mortality in cases of tetanus infection.

Oxygen and pulse oximetry in childhood pneumonia: surveys of clinicians and student clinicians in Cambodia

To better understand the availability of oxygen and pulse oximetry, barriers to use, clinician perceptions and practices regarding their role in the management of childhood pneumonia, and the formal education and training regarding these technologies received by student clinicians in Cambodia. In the clinician survey, we surveyed 81 clinicians practising at all national paediatric, provincial and district referral hospitals throughout Cambodia. Respondents were primarily physicians whose scope of practice included paediatrics, and most reported the presence of oxygen (93% (95% confidence interval (CI) [87, 98])) but less availability of pulse oximetry (51% (95% CI [39, 61])). Common barriers to use included a lack of policies and guidelines, as well as a lack of training. In the student clinician survey, 332 graduating medical and nursing students were surveyed, and most reported learning about oxygen (96% (95% CI [94, 98])) and pulse oximetry (72% (95% CI [67, 77])) during their training. Data from both surveys indicate that despite their utility, oxygen and pulse oximetry may be underused in Cambodia. The reported barriers and perceptions of the tools indicate a clear role for improved training for clinicians and students on the use of oxygen and pulse oximetry, the value of oxygen and pulse oximetry for managing childhood pneumonia, and the need for improved policies and guidelines governing their use.

Quality of maternity care practices of skilled birth attendants in Cambodia

The World Health Organization's recommended package of interventions for the integrated management of pregnancy and childbirth provides guidance for the use of evidence-based interventions to ensure the best outcomes for mother and newborn. However, the extent to which skilled birth attendants (SBAs) follow evidence-based guidelines is not known. There are few studies into childbirth practices of SBAs in Cambodia. The aim of this study was to observe practices of SBAs during labour, birth and the immediate post-partum period and their consistency with evidence-based guidelines. A structured non-participant observation study was undertaken. Data were collected using an observational checklist of evidence-based practices adapted from the Cambodian clinical assessment tools for associate degree in midwifery. Maternity care settings in one provincial hospital, two district referral hospitals and two health centres in one province of Cambodia were purposively selected. Twenty-five SBAs who attended 40 women during labour, birth and the postnatal period were observed. The results showed that the use of the partograph was low; birth companions were not permitted; cleanliness during birth was lacking; management of the third stage of labour was inappropriate; monitoring of mother and baby in the early postnatal period was lacking; the SBAs lacked skills in neonatal resuscitation; skin-to-skin contact with the newborn and early breastfeeding were rare; and intramuscular injection of vitamin K varied. The findings suggest that the current SBA practices during labour, birth and the immediate post-partum period in one province of Cambodia are not consistent with evidence-based guidelines. Service improvements that address evidence-based practices are likely to have an impact on clean and safe childbirth, thereby enhancing outcomes for Cambodia women.

The epidemiology of hospitalization with diarrhea in rural Kenya: the utility of existing health facility data in developing countries

In developing countries where prospective surveillance is resource-intensive, existing hospital data can define incidence, mortality, and risk factors that can help target interventions and track trends in disease burden. We reviewed hospitalizations from 2001 to 2003 at all inpatient facilities in Bondo District, Kenya. Diarrhea was responsible for 11.2% (n=2158) of hospitalizations. The annual incidence was 550 and 216 per 100,000 persons aged <5 and > or =5 years, respectively. The incidence was highest in infants (1138 per 100,000 persons), decreased in older children, peaked again among 20-29-year-olds (341 per 100,000), and declined among those > or =65 years (157 per 100,000). Female adults had higher incidence than males (rate ratio=1.84, 95% CI 1.61-2.10). Incidence decreased with distance from the district referral hospital (4.5% per kilometer, p<0.0001) and from the nearest inpatient facility (6.6% per kilometer, p=0.012). Case-fatality was high (8.0%), and was higher among adults than young children. Co-diagnosis with malaria, pneumonia, HIV, and tuberculosis was common. Peak diarrhea incidence fell one to two months after heavy rains. The trends revealed here provide useful data for public health priority setting and planning, including preventative interventions. The utility of such data justifies renewed efforts to establish and strengthen health management information systems in developing countries.

One drug or two? Step‐down therapy after i.v. antibiotics for community‐acquired pneumonia

The aim of the study was to describe the oral antibiotics prescribed as step-down therapy for patients hospitalized for community-acquired pneumonia (CAP). A comparative audit of patient records in a Sydney teaching hospital, a district referral hospital and a regional hospital was carried out. Patients older than 15 years admitted between 1 July 2004 and 31 December 2004 with a diagnosis of CAP were identified by diagnostic code. The medical records were reviewed for patient demographics, the specialty of the attending physician, comorbidities, adverse drug events, relevant microbiological results and the antibiotic therapy prescribed for the treatment of pneumonia. Cases were randomly selected from all pneumonia admissions, with approximately equal numbers from urban and regional hospitals. One hundred and ninety-six admissions for CAP (in 193 patients) were included in this review. Patients were predominantly cared for by respiratory physicians (62%) and geriatricians (14%). Eighty-nine per cent of patients received dual antibiotic therapy on admission. For patients commenced on two antibiotics, 62% were prescribed two oral antibiotics after completing i.v. therapy, 27% were prescribed one oral agent and 11% were prescribed no step-down therapy. Geographic location and the presence of a documented antibiotic allergy affected prescribing practice. Neither the specialty of the attending medical officer nor the identification of a likely pathogen affected prescribing practice. Although most of the patients with CAP were initially prescribed two antibiotics, there was considerable variability in whether one, two or no oral agents were prescribed as step-down therapy.

Low hepatitis B vaccine coverage among health care workers detected by a blood-borne exposure active surveillance programme

To describe the incidence of exposure to blood and to determine hepatitis B vaccine coverage among healthcare workers. Descriptive, longitudinal study. District referral hospital with 260 beds. Case definition: exposure reported from January 1999 to December 2001. Viral markers were investigated in patients and sources. The incidence density (ID) was calculated and logistic regression analysis was performed. Three hundred sixty-seven exposures were reported, of which 94.5% were percutaneous and 5.4% were myocutaneous. The ID was 0.3 per 1000 healthcare workers-days. The highest area- and category-specific ID were observed among students (0.5 per 1000 healthcare workers-days) and the sterilization center (0.9 per 1000 healthcare workers-days). At the time of exposure, 78% of the exposed healthcare workers had been vaccinated against hepatitis B. The absence of vaccination against hepatitis B was associated with older subjects and with occupations other than doctor or nurse. There were no cases of seroconversion. The risk of exposure to blood was related to the type of work and the area of the hospital. No cases of transmission of hepatitis B virus, hepatitis C virus or HIV were detected. Hepatitis B vaccine coverage should be increased in our center. Describir la incidencia de exposiciones a sangre y comprobar la cobertura vacunal frente a hepatitis B en el personal sanitario. Estudio descriptivo longitudinal realizado en un hospital comarcal de referencia con 260 camas. Se valoraron todas las exposiciones comunicadas desde enero de 1999 a diciembre de 2001. Se realizó el estudio de los marcadores virales de los pacientes y las fuentes. Se calculó la densidad de incidencia (DI) y se realizó un análisis de regresión logística. Se comunicaron 367 exposiciones, un 94,5% percutá-neas y un 5,4% mucocutáneas. La DI fue 0,3 por 1.000 personal sanitario-días. La DI por áreas y categorías más elevadas correspondieron a los estudiantes (0,5/1.000 personal sanitario-días) y el centro de esterilización (0,9/1.000 personal sanitario-días). En el momento de la exposición, el 78% del personal sanitario expuesto estaba vacunado frente a la hepatitis B. La ausencia de vacunación se asoció con los sujetos de más edad y los que no eran médicos ni enfermeras. No se produjo ninguna seroconversión. El riesgo de exposición a sangre se relacionó con el tipo de trabajo y el área del hospital. No se produjo transmisión de los virus de la hepatitis B y C ni del virus de la inmunodeficiencia humana (VIH). Es necesario mejorar la cobertura vacunal frente a la hepatitis B en el personal sanitario de nuestro centro.

Effect of maternal HIV and malaria infection on pregnancy and perinatal outcome in Zimbabwe.

To investigate the effect of isolated or concomitant infection with malaria and HIV on pregnancy and neonatal outcome. Data were collected on pregnant women admitted during the rainy seasons in the obstetric division of a district referral hospital in northern Zimbabwe in 2000 and 2001. The effects of malaria and HIV infection were determined by multivariate analysis. The prevalence of HIV seropositivity and symptomatic malaria in 986 pregnant women was 8.3% and 14.7%, respectively. HIV-infected women were more likely to develop malaria attacks during pregnancy than seronegative women (odds ratio [OR] = 3.96, 95% confidence interval (CI): 2.42-6.46). Malaria and HIV infections were associated with increased risk of stillbirth (OR = 4.74, 95% CI: 1.34-16.78) and preterm delivery (OR = 4.10, 95% CI: 2.17-7.75), respectively. They were independently associated with increased risk of low birth weight (malaria: OR = 10.09, 95% CI: 6.50-15.65; HIV: OR = 3.16, 95% CI: 1.80-5.54) and very low birth weight (malaria: OR = 5.04, 95% CI: 1.00-25.43; HIV: OR = 10.74, 95% CI: 2.12-54.41), low Apgar score (malaria: OR = 4.45, 95% CI: 1.42-13.94; HIV: OR = 5.94, 95% CI: 1.66-21.30), and fetal growth restriction (malaria: OR = 3.98, 95% CI: 2.51-6.30; HIV: OR = 4.07, 95% CI: 2.40-6.92). Dual infection with malaria and HIV was associated with increased risk of maternal, perinatal, and early infant death. Women with single HIV or malaria infection have a significantly increased risk of adverse outcomes of pregnancy and childbirth. Dual infection has additional detrimental effects on maternal and infant survival in an area where HIV and malaria coexist.

An analysis of the first 300 fibreoptic bronchoscopies at the brompton hospital

We report the results of the first 300 fibreoptic bronchoscopies carried out at the Brompton Hospital. Positive cell typing was possible in only 36% of the visible carcinomas in the first 150 patients, but in 74% of the second 150. The reasons for this difference are discussed. We suggest that fibreoptic bronchoscopy be carried out in district referral hospitals where sufficient experience can be gained to produce good results. Our results suggest that the trap specimen should be examined routinely for acid-fast bacilli, for malignant cells only if biopsy is negative and not at all for other bacteria. With experience good results can be obtained by physicians and the expertise gained is invaluable in the investigation and treatment of a wide range of patients, many of whom do not need surgical treatment.