Illness In sub-Saharan Africa Research Articles

Perceptions of causes and treatment of mental illness among traditional health practitioners in Johannesburg, South Africa.

Mental disorders are among the most poorly treated illnesses in sub-Saharan Africa. It is estimated that 70%-80% of South Africans consult traditional health practitioners for the treatment of psychological ailments. As traditional health practitioners maintain a strong role in assessing and treating patients with mental illness in this context, this study contributes to the burgeoning research literature on the topic. Semi-structured in-depth interviews were conducted with 18 traditional health practitioners in Johannesburg, South Africa, between January and May 2022. Interviews were transcribed and translated into English. The data were managed using NVivo 12 software and thematically analysed. Traditional health practitioners interviewed generally perceived mental illness to be of supernatural causation, either as a result of bewitchment, a calling for patients to become THPs themselves, due to displeased ancestors, or due to natural causes. Traditional health practitioners identified eight primary treatments that they use for treating mental illness. Among these were throwing of bones (tinhlolo) to start communicating with ancestors, steaming (ukufutha) to start a cleansing process, sneezing (umbhemiso) to forcefully dispel the spirit causing the illness, induced vomiting (phalaza), and the administration of laxatives (mahlabekufeni) to remove the spirits poisoning the body as well as animal sacrifice to purge spirits and communicate with ancestors. This is all followed by cutting (ukucaba), which is the final part of the treatment and ensures that the evil spirit cannot return. Due to the ubiquity of traditional health practitioner usage for mental illness in sub-Saharan Africa, it is essential to understand what conceptions traditional health practitioners have of the aetiology of these disorders as well as their modalities for administering treatment.

The use of traditional medicine practitioners for childhood illness in sub-Saharan Africa

The use of traditional medicine practitioners for childhood illness in sub-Saharan Africa

Health itinerary-related survival of children under-five with severe malaria or bloodstream infection, DR Congo.

Prompt appropriate treatment reduces mortality of severe febrile illness in sub-Saharan Africa. We studied the health itinerary of children under-five admitted to the hospital with severe febrile illness in a setting endemic for Plasmodium falciparum (Pf) malaria and invasive non-typhoidal Salmonella infections, identified delaying factors and assessed their associations with in-hospital death. Health itinerary data of this cohort study were collected during 6 months by interviewing caretakers of children (>28 days - <5 years) admitted with suspected bloodstream infection to Kisantu district hospital, DR Congo. The cohort was followed until discharge to assess in-hospital death. From 784 enrolled children, 36.1% were admitted >3 days after fever onset. This long health itinerary was more frequent in children with bacterial bloodstream infection (52.9% (63/119)) than in children with severe Pf malaria (31.0% (97/313)). Long health itinerary was associated with in-hospital death (OR = 2.1, p = 0.007) and two thirds of deaths occurred during the first 3 days of admission. Case fatality was higher in bloodstream infection (22.8% (26/114)) compared to severe Pf malaria (2.6%, 8/309). Bloodstream infections were mainly (74.8% (89/119)) caused by non-typhoidal Salmonella. Bloodstream infections occurred in 20/43 children who died in-hospital before possible enrolment and non-typhoidal Salmonella caused 16 out of these 20 bloodstream infections. Delaying factors associated with in-hospital death were consulting traditional, private and/or multiple providers, rural residence, prehospital intravenous therapy, and prehospital overnight stays. Use of antibiotics reserved for hospital use, intravenous therapy and prehospital overnight stays were most frequent in the private sector. Long health itineraries delayed appropriate treatment of bloodstream infections in children under-five and were associated with increased in-hospital mortality. Non-typhoidal Salmonella were the main cause of bloodstream infection and had high case fatality. NCT04289688.

Characterising paediatric mortality during and after acute illness in Sub-Saharan Africa and South Asia: a secondary analysis of the CHAIN cohort using a machine learning approach

A better understanding of which children are likely to die during acute illness will help clinicians and policy makers target resources at the most vulnerable children. We used machine learning to characterise mortality in the 30-days following admission and the 180-days after discharge from nine hospitals in low and middle-income countries (LMIC). A cohort of 3101 children aged 2-24 months were recruited at admission to hospital for any acute illness in Bangladesh (Dhaka and Matlab Hospitals), Pakistan (Civil Hospital Karachi), Kenya (Kilifi, Mbagathi, and Migori Hospitals), Uganda (Mulago Hospital), Malawi (Queen Elizabeth Central Hospital), and Burkina Faso (Banfora Hospital) from November 2016 to January 2019. To record mortality, children were observed during their hospitalisation and for 180 days post-discharge. Extreme gradient boosted models of death within 30 days of admission and mortality in the 180 days following discharge were built. Clusters of mortality sharing similar characteristics were identified from the models using Shapley additive values with spectral clustering. Anthropometric and laboratory parameters were the most influential predictors of both 30-day and post-discharge mortality. No WHO/IMCI syndromes were among the 25 most influential mortality predictors of mortality. For 30-day mortality, two lower-risk clusters (N=1915, 61%) included children with higher-than-average anthropometry (1% died, 95% CI: 0-2), and children without signs of severe illness (3% died, 95% CI: 2-4%). The two highest risk 30-day mortality clusters (N=118, 4%) were characterised by high urea and creatinine (70% died, 95% CI: 62-82%); and nutritional oedema with low platelets and reduced consciousness (97% died, 95% CI: 92-100%). For post-discharge mortality risk, two low-risk clusters (N=1753, 61%) were defined by higher-than-average anthropometry (0% died, 95% CI: 0-1%), and gastroenteritis with lower-than-average anthropometry and without major laboratory abnormalities (0% died, 95% CI: 0-1%). Two highest risk post-discharge clusters (N=267, 9%) included children leaving against medical advice (30% died, 95% CI: 25-37%), and severely-low anthropometry with signs of illness at discharge (46% died, 95% CI: 34-62%). WHO clinical syndromes are not sufficient at predicting risk. Integrating basic laboratory features such as urea, creatinine, red blood cell, lymphocyte and platelet counts into guidelines may strengthen efforts to identify high-risk children during paediatric hospitalisations. Bill & Melinda Gates FoundationOPP1131320.

Perceptions about mental healthcare for people with epilepsy in Africa

BackgroundMental illness is commonly comorbid with epilepsy. In sub-Saharan Africa there exists limited access to neurological and psychiatric services predisposing to a “treatment gap” in epilepsy and mental healthcare. AimsTo understand healthcare providers’ knowledge, attitudes, and management practices toward epilepsy and comorbid mental illness in sub-Saharan Africa. MethodsA cross-sectional online survey following the STROBE guidance was conducted among healthcare providers in sub-Saharan Africa. Eleven questions looking to ascertain clinician demographics, knowledge of epilepsy, and comorbid mental illness as well as management practices were developed. FindingsOf 203 responses most (92%) respondents recognized a bi-directional relationship between mental health and epilepsy. However, mental illness screening in people newly diagnosed with epilepsy was infrequently performed (14%). Only 1 in 7 (16%) respondents had high confidence in their clinical competence at managing psychiatric comorbidities. Most would value further training (74%) and improvements to be made in current management practices within their local healthcare settings (94%). ConclusionsThis pilot study highlights the need to improve the awareness of management of mental disorders in populations with epilepsy within sub-Saharan Africa in health providers there.

Does attitude towards wife beating determine infant feeding practices during diarrheal illness\xa0in sub-Saharan Africa?

BackgroundInappropriate feeding practices of children during illness remains a public health problem globally, particularly in sub-Saharan Africa (SSA). One strategy to improve child health outcomes is through women empowerment—measured by wife beating attitude. However, the role of attitude towards wife beating in child feeding practices has not been comprehensively studied. Therefore, we investigated the association between women's attitude towards wife beating and child feeding practices during childhood diarrhea in 28 countries in SSA.MethodsWe analyzed data from the Demographic and Health Survey on 40,720 children under 5 years. Bivariate and multivariate binary logistic regression analyses were applied to assess the association between women's attitude towards wife beating and child feeding practices. The results were presented using adjusted odds ratio (aOR) with 95% confidence intervals (CIs).ResultsThe pooled results showed that appropriate feeding practices during diarrheal illness among under-five children was 9.3% in SSA, varying from 0.4% in Burkina Faso to 21.1% in Kenya. Regarding regional coverage, the highest coverage was observed in Central Africa (9.3%) followed by East Africa (5.5%), Southern Africa (4.8%), and West Africa (4.2%). Women who disagreed with wife-beating practices had higher odds of proper child feeding practices during childhood diarrhea compared to those who justified wife-beating practices (aOR = 2.02, 95% CI; 1.17–3.48).ConclusionThe findings suggest that women’s disagreement with wife beating is strongly associated with proper child feeding practices during diarrheal illness in SSA. Proactive measures and interventions designed to change attitudes towards wife-beating practices are crucial to improving proper feeding practices in SSA.

High patient acceptability but low coverage of provider-initiated HIV testing among adult outpatients with symptoms of acute infectious illness in coastal Kenya.

BackgroundOnly approximately one in five adults are offered HIV testing by providers when seeking care for symptoms of acute illness in Sub-Saharan Africa. Our aims were to estimate testing coverage and identify predictors of provider-initiated testing and counselling (PITC) and barriers to PITC implementation in this population.MethodsWe assessed HIV testing coverage among adult outpatients 18–39 years of age at four public and two private health facilities in coastal Kenya, during a 3- to 6-month surveillance period at each facility. A subset of patients who reported symptoms including fever, diarrhoea, fatigue, body aches, sore throat or genital ulcers were enrolled to complete a questionnaire independently of PITC offer. We assessed predictors of PITC in this population using generalised estimating equations and identified barriers to offering PITC through focus group discussion with healthcare workers (HCW) at each facility.ResultsOverall PITC coverage was 13.7% (1600 of 11,637 adults tested), with 1.9% (30) testing positive. Among 1,374 participants enrolled due to symptoms, 378 (27.5%) were offered PITC and 352 (25.6%) were tested, of whom 3.7% (13) tested positive. Among participants offered HIV testing, 93.1% accepted it; among participants not offered testing, 92.8% would have taken an HIV test if offered. The odds of completed PITC were increased among older participants (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.4–2.1 for 30–39 years, relative to 18–24 years), men (aOR 1.3, 95% CI 1.1–1.7); casual labourers (aOR 1.3, 95% CI 1.0–1.7); those paying by cash (aOR 1.2, 95% CI 1.0–1.4) or insurance (aOR 3.0, 95% CI 1.5–5.8); participants with fever (aOR 1.5, 95% CI 1.2–1.8) or genital ulcers (aOR 4.0, 95% CI 2.7–6.0); and who had tested for HIV >1 year ago (aOR 1.4, 95% CI 1.0–2.0) or had never tested (aOR 2.2, 95% CI 1.5–3.1). Provider barriers to PITC implementation included lack of HCW knowledge and confidence implementing guidelines, limited capacity and health systems constraints.ConclusionPITC coverage was low, though most patients would accept testing if offered. Missed opportunities to promote testing during care-seeking were common and innovative solutions are needed.

Point-of-Care Biomarkers to Guide Antibiotic Prescription for Acute Febrile Illness in Sub-Saharan Africa: Promises and Caveats.

Empiric malaria treatment in Sub-Saharan Africa has significantly decreased with the scaling-up of malaria rapid diagnostic tests; this coincided with a pronounced increase in empiric antibiotic prescriptions. In high-income countries, guidance for antibiotic prescriptions using biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) has reduced antibiotic use while safe-guarding patient safety. Importantly, several low-cost point-of-care CRP/PCT tests are currently available. However, only a few studies on the role of CRP/PCT in differentiating bacterial vs viral infections in acute febrile illness have been conducted in Sub-Saharan Africa. Studies from Central and West Africa (most of which is malaria-endemic) are particularly scarce, and only 1 has included adults. The evidence base for point-of-care use of CRP/PCT biomarkers in acute fever in Sub-Saharan Africa should be urgently built. Before engaging in clinical trials to assess clinical impact, pilot studies should be conducted to address key knowledge gaps including recommended CRP/PCT cutoff values and the effect of malaria coinfection.

The burden of urological disease in Zomba, Malawi: A needs assessment in a sub-Saharan tertiary care center.

A large part of the developing world continues to lack access to surgical care. Urology remains one of the least represented surgical subspecialties in global health. To begin understanding the burden of urological illness in sub-Saharan Africa, we sought to characterize all patients presenting to a tertiary care hospital in Malawi with a urological diagnosis or related complaint in the past year. Retrospective review of the surgical clinic and surgical theater record books at Zomba Central Hospital (ZCH) was performed over a one-year time span. Patients presenting with urological diagnoses or undergoing a urological procedure under local or general anesthetic in the operating theater were identified and entered into a database. We reviewed 440 clinical patients. The most common clinical presentations were for urinary retention (34.7%) and lower urinary tract symptoms (15.5%). A total of 182 surgical cases were reviewed. The most common diagnoses for surgical patients were urethral stricture disease (22%), bladder masses (17%), and benign prostatic hyperplasia (BPH) symptoms (14.8%). Urethral stricture-related procedures, including direct visual internal urethrotomy and urethral dilatation, were the most common (14.2% and 7.7%, respectively). BPH-related procedures, including simple prostatectomy and transurethral resection of the prostate were the second most common (6.7% and 8.2%, respectively). Urethral stricture disease, BPH, and urinary retention represent the clinical diagnoses with the highest burden of visits. Despite these numbers, few definitive procedures are performed annually. Further focus on urological training in sub-Saharan Africa should focus on these conditions and their surgical management.

Economic burden of caregiving for persons with severe mental illness in sub-Saharan Africa: A systematic review.

BackgroundOver the past two decades, the focus of mental health care has shifted from institutionalisation to community-based programs and short hospital stays. This change means that there is an increased role for caregivers, mostly family members, in managing persons with mental illness. Although there is evidence to support the benefits of deinstitutionalisation of mental health care, there are also indications of substantial burden experienced by caregivers; the evidence of which is limited in sub-Saharan Africa. However, knowledge of the nature and extent of this burden can inform the planning of mental health services that will not only benefit patients, but also caregivers and households.ObjectiveTo systematically review the available evidence on the economic burden of severe mental illness on primary family caregivers in sub-Saharan Africa.MethodsA comprehensive search was conducted in Pubmed, CINAHL, Econlit and Web of Science with no date limitations up to September 2016 using keywords such as "burden", "cost of illness" and "economic burden" to identify relevant published literature. Articles were appraised using a standardised data extraction tool covering themes such as physical, psychological and socioeconomic burden.ResultsSeven papers were included in the review. Caregivers were mostly family members with a mean age of 46.34, female and unemployed. Five out of seven studies (71%) estimated the full economic burden of severe mental illness on caregivers. The remainder of studies just described the caregiver burden. All seven papers reported moderate to severe caregiver burden characterised by financial constraint, productivity loss and lost employment. The caregiver’s level of income and employment status, severity of patient's condition and duration of mental illness were reported to negatively affect the economic burden experienced by caregivers.ConclusionThere is paucity of studies reporting the burden of severe mental illness on caregivers in sub-Saharan Africa. Further research is needed to present the nature and extent of this burden to inform service planning and policymaking.

Outcomes of HIV-associated pneumocystis pneumonia at a South African referral hospital.

HIV-associated pneumocystis pneumonia (PCP) is increasingly recognized as an important cause of severe respiratory illness in sub-Saharan Africa. Outcomes of HIV-infected patients with PCP, especially those requiring intensive care unit (ICU) admission, have not been adequately studied in sub-Saharan Africa. The aim of this study was to describe the clinical phenotype and outcomes of HIV-associated PCP in a group of hospitalized South African patients, and to identify predictors of mortality. We conducted a retrospective record review at an academic referral center in Cape Town. HIV-infected patients over the age of 18 years with definite (any positive laboratory test) or probable PCP (defined according to the WHO/CDC clinical case definition) were included. The primary outcome measure was 90-day mortality. Logistic regression and Cox proportional hazards models were constructed to identify factors associated with mortality. We screened 562 test requests between 1 May 2004 and 31 April 2015; 124 PCP cases (68 confirmed and 56 probable) were included in the analysis. Median age was 34 years (interquartile range, IQR, 29 to 41), 89 (72%) were female, and median CD4 cell count was 26 cells/mm3 (IQR 12 to 70). Patients admitted to the ICU (n = 42) had more severe impairment of gas exchange (median ratio of arterial to inspired oxygen (PaO2:FiO2) 158 mmHg vs. 243 mmHg, p < 0.0001), and increased markers of systemic inflammation compared to those admitted to the ward (n = 82). Twenty-nine (23.6%) patients were newly-diagnosed with tuberculosis during their admission. Twenty-six (61.9%) patients admitted to ICU and 21 (25.9%) admitted to the ward had died at 90-days post-admission. Significant predictors of 90-day mortality included PaO2:FiO2 ratio (aOR 3.7; 95% CI, 1.1 to 12.9 for every 50 mgHg decrease), serum LDH (aOR 2.1; 95% CI, 1.1 to 4.1 for every 500 U/L increase), and concomitant antituberculosis therapy (aOR 82; 95% CI, 1.9 to 3525.4; P = 0.021). PaO2:FiO2 < 100 mmHg was significantly associated with inpatient death (aHR 3.8; 95% CI, 1.6 to 8.9; P = 0.003). HIV-associated PCP was associated with a severe clinical phenotype and high rates of tuberculosis co-infection. Mortality was high, particularly in patients admitted to the ICU, but was comparable to other settings. Prognostic indictors could be used to inform ICU admission policy for patients with this condition.

Applied Graph Transformation and Verification With Use Cases in Malaria Surveillance

Malaria is one of the leading causes of death and illness in sub-Saharan Africa. In order to make timely decisions for control and elimination of malaria, researchers, and clinicians need access to integrated consistent knowledge sources. These knowledge sources often rely on dynamic and constantly changing databases and ontologies. It is crucial to manage changes and ensure that these changes do not cause inconsistencies in the integrated knowledge source. To this end, we propose the use of a formal model using graph transformations to monitor and manage the changes in a coherent way while preserving the consistency of the integrated structure through classical verification. In this paper, we use an algorithmic approach to graph transformation, instead of the more classical algebraic approach, to express the evolution of the data and ontological structures. In this model, each transformation is the result of applying rules to the graph, where the left-hand side is used to select a subgraph and the right-hand side is a sequence of elementary actions to be performed. Strategies are used to define how transformation rules should be applied. This approach enables us to define a Hoare-like calculus that can be used to verify the transformations and manage the changes. In this paper, we demonstrate the feasibility and significance of the proposed method through different use cases in malaria surveillance.

Perceived expressed emotions in relatives of patients with severe mental illness: A comparative study

There is paucity of studies on expressed emotion (EE) in families of patients with severe mental illness in sub-Saharan Africa. This study aimed to assess and compare the levels of expressed emotion (LEE) in relatives of patients with schizophrenia and bipolar affective disorder attending an out-patient clinic in Southwestern Nigeria. One hundred and forty consecutive clinic attendees with Mini-Plus diagnosis of schizophrenia and bipolar affective disorder and 140 accompanying relatives were recruited. The patients and relatives were interviewed using a socio-demographic questionnaire. The perceived level of expressed emotion was assessed using the client version of the Level of Expressed Emotion Questionnaire (LEEQ). Although, the prevalence of high expressed emotion was higher among relatives of patients with schizophrenia when compared with relatives of patients with bipolar affective disorder (41% vs 37%), the difference was not statistically significant. The socio-demographic characteristics of the relatives of patients with these disorders were not significantly related to high EE. High expressed emotion is just as prevalent among relatives of patients with bipolar affective disorder as among relatives of patients with schizophrenia and clinicians should give similar attention to early detection of high EE and intervention in this population of patients and their relatives.

Rickettsia felis Infection in Febrile Children, Ghana.

AbstractRickettsial infections are an underrecognized cause of febrile illness in sub-Saharan Africa. To evaluate the epidemiology and clinical features of rickettsial disease in pediatric patients in Ghana, we screened blood samples from febrile children aged less than 15 years presenting to an outpatient department in Ghana's Ashanti Region for the presence of rickettsial DNA. We detected Rickettsia felis in 7/470 (1.5%) blood samples, using two independent real-time polymerase chain reactions. No other Rickettsia species were found. R. felis was detected repeatedly in one patient, and coinfection with Plasmodium falciparum was found in 3/7 samples. Symptoms apart from fever included cough (6/7) and vomiting (4/7). None of the R. felis-positive patients reported a rash. This study is the first report on R. felis in Ghana and adds to the growing evidence for its widespread occurrence with and without malaria coinfection in sub-Saharan Africa.

Caregiver Decision-Making: Household Response to Child Illness in sub-Saharan Africa.

We draw upon a framework outlining household recognition and response to child illness proposed by Colvin and colleagues (2013) to examine factors predictive of treatment sought for a recent child illness. In particular, we model whether no treatment, middle layer treatment (traditional healer, pharmacy, community health worker, etc.), or biomedical treatment was sought for recent episodes of diarrhea, fever, or cough. Based on multinomial, multilevel analyses of Demographic and Health Surveys from 19 countries in sub-Saharan Africa, we determine that if women have no say in their own healthcare, they are unlikely to seek treatment in response to child illness. We find that women in sub-Saharan Africa need healthcare knowledge, the ability to make healthcare decisions, as well as resources to negotiate cost and travel, in order to access biomedical treatment. Past experience with medical services such as prenatal care and a skilled birth attendant also increase the odds that biomedical treatment for child illness is sought. We conclude that caregiver decision-making in response to child illness within households is critical to reducing child morbidity and mortality in sub-Saharan Africa.

A Multicountry Molecular Analysis of Salmonella enterica Serovar Typhi With Reduced Susceptibility to Ciprofloxacin in Sub-Saharan Africa.

Salmonella enterica serovar Typhi is a predominant cause of bloodstream infections in sub-Saharan Africa (SSA). Increasing numbers of S. Typhi with resistance to ciprofloxacin have been reported from different parts of the world. However, data from SSA are limited. In this study, we aimed to measure the ciprofloxacin susceptibility of S. Typhi isolated from patients with febrile illness in SSA. Febrile patients from 9 sites within 6 countries in SSA with a body temperature of ≥38.0°C were enrolled in this study. Blood samples were obtained for bacterial culture, and Salmonella isolates were identified biochemically and confirmed by multiplex polymerase chain reaction (PCR). Antimicrobial susceptibility of all Salmonella isolates was performed by disk diffusion test, and minimum inhibitory concentrations (MICs) against ciprofloxacin were measured by Etest. All Salmonella isolates with reduced susceptibility to ciprofloxacin (MIC > 0.06 µg/mL) were screened for mutations in quinolone resistance-determining regions in target genes, and the presence of plasmid-mediated quinolone resistance (PMQR) genes was assessed by PCR. A total of 8161 blood cultures were performed, and 100 (1.2%) S. Typhi, 2 (<0.1%) Salmonella enterica serovar Paratyphi A, and 27 (0.3%) nontyphoid Salmonella (NTS) were isolated. Multidrug-resistant S. Typhi were isolated in Kenya (79% [n = 38]) and Tanzania (89% [n = 8]) only. Reduced ciprofloxacin-susceptible (22% [n = 11]) S. Typhi were isolated only in Kenya. Among those 11 isolates, all had a Glu133Gly mutation in the gyrA gene combined with either a gyrA (Ser83Phe) or gyrB mutation (Ser464Phe). One Salmonella Paratyphi A isolate with reduced susceptibility to ciprofloxacin was found in Senegal, with 1 mutation in gyrA (Ser83Phe) and a second mutation in parC (Ser57Phe). Mutations in the parE gene and PMQR genes were not detected in any isolate. Salmonella Typhi with reduced susceptibility to ciprofloxacin was not distributed homogenously throughout SSA. Its prevalence was very high in Kenya, and was not observed in other study countries. Continuous monitoring of antimicrobial susceptibility is required to follow the potential spread of antimicrobial-resistant isolates throughout SSA.

Causal impact of malnutrition on mortality among adults hospitalized for medical illness in sub-Saharan Africa: what is the role of severe sepsis?

In sub-Saharan Africa, malnutrition is associated with mortality in adults hospitalized for medical illness. However, it remains unclear whether this association is causal, and if causal, what the potential mediators are. We assessed whether malnutrition is causally related to mortality among hospitalized adults, and whether severe sepsis plays a mediating role. We analyzed data from a cohort study of adults hospitalized for any medical illness in Uganda. We measured malnutrition using mid-upper arm circumference (MUAC). We used a directed acyclic graph to identify a minimum sufficient adjustment set of confounders in order to estimate the overall effects of malnutrition on mortality. We then used recently developed statistical methods to determine whether mortality in malnourished patients is mediated by severe sepsis. We analyzed data of 318 adults. Median age was 37 (interquartile range [IQR] 27 to 56), and 25 % (n = 80) were malnourished according to MUAC. Malnourished patients were more likely to be HIV positive (64 % versus 39 %, p < 0.001), more severely ill (median MEWS 5, IQR 3 to 7 versus 4, IQR 2 to 6, P = 0.003), and to have both any sepsis (66 % versus 39 %, p < 0.001) and severe sepsis (51 % versus 20 %, P < 0.001) compared to normally nourished patients. After adjusting for the modified early warning score at admission, tuberculosis, HIV status, education status, age, and sex, malnourished patients remained at 3.0-fold (95 % CI: 1.5, 6.1, P = 0.002) increased odds of having severe sepsis at admission, and at 2.1-fold (95 % confidence interval [CI]: 1.2, 3.7, P = 0.008) increased odds of dying by 30 days post-admission. Only a small proportion of the effects of malnutrition on mortality were mediated by severe sepsis; overall, malnutrition increased the risk of death by 16.8 percentage points (95 % CI: 4.1, 29.4), but only 1.1 percentage points (95 % CI: −2.1, 4.4) absolute risk difference was mediated by severe sepsis. Our data suggest that malnutrition increases mortality in adults hospitalized for medical illness; thus, interventions against malnutrition in this population may reduce mortality. As severe sepsis did not mediate a large proportion of the effects of malnutrition on mortality, future studies are recommended to investigate other potential mediators.

Urbanicity and Paediatric Bacteraemia in Ghana-A Case-Control Study within a Rural-Urban Transition Zone.

BackgroundSystemic bacterial infections are a major cause of paediatric febrile illness in sub-Saharan Africa. Aim of this study was to assess the effects of social and geographical determinants on the risk of bacteraemia in a rural-urban transition zone in Ghana.MethodsChildren below 15 years of age with fever were recruited at an outpatient department in the suburban belt of Kumasi, Ghana’s second largest city. Blood was taken for bacterial culture and malaria diagnostics. The socio-economic status of participants was calculated using Principle Component Analysis. A scale, based on key urban characteristics, was established to quantify urbanicity for all communities in the hospital catchment area. A case-control analysis was conducted, where children with and without bacteraemia were cases and controls, respectively.ResultsBacteraemia was detected in 72 (3.1%) of 2,306 hospital visits. Non-typhoidal Salmonella (NTS; n = 24; 33.3%) and Salmonella typhi (n = 18; 25.0%) were the most common isolates. Logistic regression analysis showed that bacteraemia was negatively associated with urbanicity (odds ratio [OR] = 0.8; 95% confidence interval [CI]: 0.7–1.0) and socio-economic status (OR = 0.8; 95% CI: 0.6–0.9). Both associations were stronger if only NTS infections were used as cases (OR = 0.5; 95% CI: 0.3–0.8 and OR = 0.6; 95% CI: 0.4–1.0, respectively).ConclusionsThe results of this study highlight the importance of individual as well as community factors as independent risk factors for invasive bacterial infection (IBI) and especially NTS. Epidemiological data support physicians, public health experts and policy makers to identify disease prevention and treatment needs in order to secure public health in the transitional societies of developing countries.

Low Bacteremia Prevalence Among Febrile Children in Areas of Differing Malaria Transmission in Rural Kenya: A Cross-Sectional Study

With malaria declining, other causes of fever may account for a substantial portion of severe childhood illness in sub-Saharan Africa. We determined prevalence, etiologies, and correlates of bacteremia among children in Western Kenya. In a cross-sectional study, febrile children aged 6 months to 15 years presenting to Kisii (low malaria endemicity) and Homabay (high malaria endemicity) Hospitals were enrolled and screened for malaria, human immunodeficiency virus (HIV) infection and bacteremia. Correlates of bacteremia were evaluated using logistic regression. Among 1476 children enrolled, 48 (3.3%) had bacteremia (23 of 734, 3.1% in Kisii and 25 of 734, 3.4% in Homabay). Salmonella spp (19 typhi and 21 nontyphoidal salmonella) accounted for 83% (40 of 48) of isolates. The distribution of Salmonella spp was similar between sites. Bacteremia was associated with incomplete vaccination (adjusted odds ratio [aOR] = 2.1; 95% confidence interval [CI], 1.1-4.1), before treatment with antimalarials (aOR = 2.7; 95% CI, 1.4-4.1), having sought care elsewhere (aOR = 2.2; 95% CI, 1.2-4.0) and lower education of caregiver (aOR = 2.5; 95% CI, 1.1-4.8). Nontyphoidal salmonella bacteremia was associated with HIV (aOR = 6.8; 95% CI, 1.1-35.1) and anemia (hemoglobin <8 g/dL) (aOR = 5.2; 95% CI, 1.4-18.9). Bacteremia was relatively uncommon, but children with HIV, anemia, incomplete vaccination, and/or persistent fever despite malaria treatment may have higher risk and may benefit from targeted bacterial culture and/or empiric antibiotic therapy.

Mental health service utilization in sub-Saharan Africa: is public mental health literacy the problem? Setting the perspectives right.

The severely constrained resources for mental health service in less-developed regions like sub-Saharan Africa underscore the need for good public mental health literacy as a potential additional mental health resource. Several studies examining the level of public knowledge about the nature and dynamics of mental illness in sub-Saharan Africa in the last decade had concluded that such knowledge was poor and had called for further public enlightenment. What was thought to be mental health 'ignorance' has also been blamed for poor mainstream service utilization. These views however assume that non-alignment of the views of community dwellers in sub-Saharan Africa with the biomedical understanding of mental illness connotes 'ignorance', and that correcting such 'ignorance' will translate to improvements in service utilization. Within the framework of contemporary thinking in mental health literacy, this paper argues that such assumptions are not culturally nuanced and may have overrated the usefulness of de-contextualized public engagement in enhancing mental health service utilization in the region. The paper concludes with a discourse on how to contextualize public mental health enlightenment in the region and the wider policy initiatives that can improve mental health service utilization.