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Baraka V, Nhama A, Aide P, Bassat Q, David A, Gesase S, Gwasupika J, Hachizovu S, Makenga G, Ntizimira CR, Obunge O, Tshefu KA, Cousin M, Otsyula N, Pathan R, Risterucci C, Su G, Manyando C. Prescription patterns and compliance with World Health Organization recommendations for the management of uncomplicated and severe malaria: A prospective, real-world study in sub-Saharan Africa. Malar J 2023; 22:215. [PMID: 37491295 PMCID: PMC10367305 DOI: 10.1186/s12936-023-04650-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND This study aimed to evaluate the gap between guidelines and local clinical practice for diagnosis and treatment of uncomplicated and severe malaria, the patient characteristics, diagnostic approach, treatment, and compliance to standard guideline recommendations. METHODS This was a multicentre, observational study conducted between October 2020 and March 2021 in which patients of all ages with symptoms suggestive of malaria and who visited a healthcare facility were prospectively enrolled in six countries in sub-Saharan Africa (The Democratic Republic of the Congo, Mozambique, Nigeria, Rwanda, The United Republic of Tanzania, and Zambia). RESULTS Of 1001 enrolled patients, 735 (73.4%) patients had confirmed malaria (based on overall judgment by investigator) at baseline (uncomplicated malaria: 598 [81.4%] and severe malaria: 137 [18.6%]). Of the confirmed malaria patients, 533 (72.5%) were administered a malaria rapid diagnostic test. The median age of patients was 11 years (range: 2 weeks-91 years) with more patients coming from rural (44.9%) than urban (30.6%) or suburban areas (24.5%). At the community level, 57.8% of patients sought advice or received treatment for malaria and 56.9% of patients took one or more drugs for their illness before coming to the study site. In terms of early access to care, 44.1% of patients came to the study site for initial visit ≥ 48 h after symptom onset. In patients with uncomplicated malaria, the most prescribed treatments were artemisinin-based combination therapy (ACT; n = 564 [94.3%]), primarily using artemether-lumefantrine (82.3%), in line with the World Health Organization (WHO) treatment guidelines. In addition, these patients received antipyretics (85.6%) and antibiotics (42.0%). However, in those with severe malaria, only 66 (48.2%) patients received parenteral treatment followed by oral ACT as per WHO guidelines, whereas 62 (45.3%) received parenteral treatment only. After receiving ambulatory care, 88.6% of patients with uncomplicated malaria were discharged and 83.2% of patients with severe malaria were discharged after hospitalization. One patient with uncomplicated malaria having multiple co-morbidities and three patients with severe malaria died. CONCLUSIONS The findings of this study suggest that the prescribed treatment in most patients with uncomplicated malaria, but not of those with severe malaria, was in alignment with the WHO recommended guidelines.
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Affiliation(s)
- Vito Baraka
- National Institute for Medical Research (NIMR), Tanga Centre, Hospital Street, P.O Box 5004, Tanga, United Republic of Tanzania.
| | - Abel Nhama
- Instituto Nacional de Saúde (INS), Ministério da Saude, Maputo, Mozambique
- Centro de Investigação em Saúde de Manhiça, Manhica, Maputo Province, Mozambique
| | - Pedro Aide
- Instituto Nacional de Saúde (INS), Ministério da Saude, Maputo, Mozambique
- Centro de Investigação em Saúde de Manhiça, Manhica, Maputo Province, Mozambique
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Manhica, Maputo Province, Mozambique
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Agatha David
- Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria
| | - Samwel Gesase
- National Institute for Medical Research (NIMR), Tanga Centre, Hospital Street, P.O Box 5004, Tanga, United Republic of Tanzania
| | | | - Sebastian Hachizovu
- Tropical Diseases Research Centre, Ndola, Zambia
- Ipafu Rural Health Centre Chingola, Chingola, Zambia
| | - Geofrey Makenga
- National Institute for Medical Research (NIMR), Tanga Centre, Hospital Street, P.O Box 5004, Tanga, United Republic of Tanzania
| | | | - Orikomaba Obunge
- Center for Malaria Research and Phytomedicine (CMRAP), University of Port Harcourt, Port Harcourt, Nigeria
| | - Kitoto Antoinette Tshefu
- The Hospital Center of Mont Amba Kinshasa, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | | | | | | | | | - Guoqin Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Oliff MS, Muniina P, Babigumira K, Phuka J, Rietveld H, Sande J, Nsona H, Lugand MM. The five continuum of care criteria that should accompany rectal artesunate interventions: lessons learned from an implementation study in Malawi. Malar J 2023; 22:108. [PMID: 36966327 PMCID: PMC10039536 DOI: 10.1186/s12936-023-04514-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/24/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Rectal artesunate (RAS) is a World Health Organization (WHO) recommended intervention that can save lives of children 6 years and younger suffering from severe malaria and living in remote areas. Access to RAS and a referral system that ensures continuity of care remains a challenge in low resource countries, raising concerns around the value of this intervention. The objective of this study was to inform RAS programming, using practical tools to enhance severe malaria continuum of care when encountered at community level. METHODS A single country two-arm-controlled study was conducted in Malawi, where pre-referral interventions are provided by community health workers (CHWs). The study populations consisted of 9 and 14 village health clinics (VHCs) respectively, including all households with children 5 years and younger. CHWs in the intervention arm were trained using a field-tested toolkit and the community had access to information, education, and communication (IEC) mounted throughout the zone. The community in the control arm had access to routine care only. Both study arms were provided with a dedicated referral booklet for danger signs, as a standard of care. RESULTS The study identified five continuum of care criteria (5 CoC Framework) to reinforce RAS programming: (1) care transitions emerged as to be dependent on a strong cue to action and proximity to an operational VHC with a resident CHWs; (2) consistency of supplies assured the population of the VHC's functionality for severe danger signs management; (3) comprehensiveness care ensured correct assessment and dosing; (4) connectivity of care between all tiers using the referral slip was feasible and perceived positively by caregivers and CHWs and (5) communication between providers from different points of care. Compliance was high throughout but optimized when administered by a sensitized CHW. Over 93% experienced a rapid improvement in the status of their child post RAS. CONCLUSION RAS cannot operate within a vacuum. The impact of this lifesaving intervention can be easily lost, unless administered as part of a system-based approach. Taken together, the 5CC Framework, identified in this study, provides a structure for future RAS practice guidelines. Trial registration number and date of registration PACTR201906720882512- June 20, 2019.
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Affiliation(s)
| | | | | | - John Phuka
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Hans Rietveld
- Medicines for Malaria Venture, MMV, Geneva, Switzerland
| | - John Sande
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi
| | - Humphreys Nsona
- Integrated Management of Childhood Illness (IMCI), Ministry of Health, Lilongwe, Malawi
| | - Maud M Lugand
- Medicines for Malaria Venture, MMV, Geneva, Switzerland.
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Etiology and clinical characteristics of pediatric acute fever among hospitalized children in an endemic malaria transmission area of Cameroon in Central Africa. PLoS One 2023; 18:e0278407. [PMID: 36693048 PMCID: PMC9873149 DOI: 10.1371/journal.pone.0278407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 11/15/2022] [Indexed: 01/25/2023] Open
Abstract
Acute fever in the majority of children in resource-limited countries is attributable to malaria and often treated without laboratory evidence. The aim of the study was to characterize acute pediatric infectious fevers (APIF) in the pediatric department of the Douala Laquintinie Hospital. A cross-sectional study was conducted among children aged 2 months to 15 years who were admitted with an acute fever (anal temperature ≥ 37.5°C less than 5 days in infants and 7 days in adolescents). 200 children were included and followed up during their hospitalization. The mean age was 3.7 (IQ25-75: 1-4.6) years. More than 3 out of 5 patients (62.5%) came from another health facility and anemia accounted for 29% of the reasons for consultation associated with fever. The main symptoms were vomiting (28%), cough (26%), convulsions (21%) and diarrhea (20%). Skin-mucosal pallor (43.0%) and hepatosplenomegaly (26.0%) were the most common physical signs encountered. Among febrile children, 116/200 (58%) were infected with at least 1 pathogen, and 1/200 (0.5%) had a fever of unknown etiology. Malaria (53% vs 80.5% presumptive) associated with anemia (95.3% of cases) was the most common pathology associated with APIF, followed by pneumonia (19.5%), meningitis (11.5%) and urinary tract infections (10% vs 54.5% presumptive). Malaria was over-diagnosed on admission and over-treated as well as urinary tract infection. A better understanding of common pathogens carriage, a better capacity for improved diagnosis and a better applied clinical algorithm for febrile illnesses in children are needed.
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Kamau A, Paton RS, Akech S, Mpimbaza A, Khazenzi C, Ogero M, Mumo E, Alegana VA, Agweyu A, Mturi N, Mohammed S, Bigogo G, Audi A, Kapisi J, Sserwanga A, Namuganga JF, Kariuki S, Otieno NA, Nyawanda BO, Olotu A, Salim N, Athuman T, Abdulla S, Mohamed AF, Mtove G, Reyburn H, Gupta S, Lourenço J, Bejon P, Snow RW. Malaria hospitalisation in East Africa: age, phenotype and transmission intensity. BMC Med 2022; 20:28. [PMID: 35081974 PMCID: PMC8793189 DOI: 10.1186/s12916-021-02224-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Understanding the age patterns of disease is necessary to target interventions to maximise cost-effective impact. New malaria chemoprevention and vaccine initiatives target young children attending routine immunisation services. Here we explore the relationships between age and severity of malaria hospitalisation versus malaria transmission intensity. METHODS Clinical data from 21 surveillance hospitals in East Africa were reviewed. Malaria admissions aged 1 month to 14 years from discrete administrative areas since 2006 were identified. Each site-time period was matched to a model estimated community-based age-corrected parasite prevalence to provide predictions of prevalence in childhood (PfPR2-10). Admission with all-cause malaria, severe malaria anaemia (SMA), respiratory distress (RD) and cerebral malaria (CM) were analysed as means and predicted probabilities from Bayesian generalised mixed models. RESULTS 52,684 malaria admissions aged 1 month to 14 years were described at 21 hospitals from 49 site-time locations where PfPR2-10 varied from < 1 to 48.7%. Twelve site-time periods were described as low transmission (PfPR2-10 < 5%), five low-moderate transmission (PfPR2-10 5-9%), 20 moderate transmission (PfPR2-10 10-29%) and 12 high transmission (PfPR2-10 ≥ 30%). The majority of malaria admissions were below 5 years of age (69-85%) and rare among children aged 10-14 years (0.7-5.4%) across all transmission settings. The mean age of all-cause malaria hospitalisation was 49.5 months (95% CI 45.1, 55.4) under low transmission compared with 34.1 months (95% CI 30.4, 38.3) at high transmission, with similar trends for each severe malaria phenotype. CM presented among older children at a mean of 48.7 months compared with 39.0 months and 33.7 months for SMA and RD, respectively. In moderate and high transmission settings, 34% and 42% of the children were aged between 2 and 23 months and so within the age range targeted by chemoprevention or vaccines. CONCLUSIONS Targeting chemoprevention or vaccination programmes to areas where community-based parasite prevalence is ≥10% is likely to match the age ranges covered by interventions (e.g. intermittent presumptive treatment in infancy to children aged 2-23 months and current vaccine age eligibility and duration of efficacy) and the age ranges of highest disease burden.
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Affiliation(s)
- Alice Kamau
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Nairobi, Kenya.
| | | | - Samuel Akech
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Arthur Mpimbaza
- Child Health and Development Centre, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Cynthia Khazenzi
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Morris Ogero
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Eda Mumo
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Victor A Alegana
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Neema Mturi
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shebe Mohammed
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Godfrey Bigogo
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Allan Audi
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - James Kapisi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Nancy A Otieno
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Bryan O Nyawanda
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Ally Olotu
- Ifakara Health Institute, Bagamoyo, Tanzania
| | - Nahya Salim
- Ifakara Health Institute, Bagamoyo, Tanzania
| | | | | | - Amina F Mohamed
- Kilimanjaro Christian Medical Centre/Joint Malaria Programme, Moshi, Tanzania
- London School of Hygiene and Tropical Medicine, London, UK
| | - George Mtove
- National Institute for Medical Research, Amani Research Centre, Muheza, Tanzania
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sunetra Gupta
- Department of Zoology, University of Oxford, Oxford, UK
| | - José Lourenço
- Department of Zoology, University of Oxford, Oxford, UK
| | - Philip Bejon
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Robert W Snow
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Anyona SB, Raballah E, Cheng Q, Hurwitz I, Ndege C, Munde E, Otieno W, Seidenberg PD, Schneider KA, Lambert CG, McMahon BH, Ouma C, Perkins DJ. Differential Gene Expression in Host Ubiquitination Processes in Childhood Malarial Anemia. Front Genet 2021; 12:764759. [PMID: 34880904 PMCID: PMC8646022 DOI: 10.3389/fgene.2021.764759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Malaria remains one of the leading global causes of childhood morbidity and mortality. In holoendemic Plasmodium falciparum transmission regions, such as western Kenya, severe malarial anemia [SMA, hemoglobin (Hb) < 6.0 g/dl] is the primary form of severe disease. Ubiquitination is essential for regulating intracellular processes involved in innate and adaptive immunity. Although dysregulation in ubiquitin molecular processes is central to the pathogenesis of multiple human diseases, the expression patterns of ubiquitination genes in SMA remain unexplored. Methods: To examine the role of the ubiquitination processes in pathogenesis of SMA, differential gene expression profiles were determined in Kenyan children (n = 44, aged <48 mos) with either mild malarial anemia (MlMA; Hb ≥9.0 g/dl; n = 23) or SMA (Hb <6.0 g/dl; n = 21) using the Qiagen Human Ubiquitination Pathway RT2 Profiler PCR Array containing a set of 84 human ubiquitination genes. Results: In children with SMA, 10 genes were down-regulated (BRCC3, FBXO3, MARCH5, RFWD2, SMURF2, UBA6, UBE2A, UBE2D1, UBE2L3, UBR1), and five genes were up-regulated (MDM2, PARK2, STUB1, UBE2E3, UBE2M). Enrichment analyses revealed Ubiquitin-Proteasomal Proteolysis as the top disrupted process, along with altered sub-networks involved in proteasomal, protein, and ubiquitin-dependent catabolic processes. Conclusion: Collectively, these novel results show that protein coding genes of the ubiquitination processes are involved in the pathogenesis of SMA.
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Affiliation(s)
- Samuel B. Anyona
- Department of Medical Biochemistry, School of Medicine, Maseno University, Maseno, Kenya,University of New Mexico-Kenya Global Health Programs, Kisumu and Siaya, Kenya,*Correspondence: Samuel B. Anyona,
| | - Evans Raballah
- University of New Mexico-Kenya Global Health Programs, Kisumu and Siaya, Kenya,Department of Medical Laboratory Sciences, School of Public Health Biomedical Sciences and Technology, Masinde Muliro University of Science and Technology, Kakamega, Kenya
| | - Qiuying Cheng
- Center for Global Health, University of New Mexico, Albuquerque, NM, United States
| | - Ivy Hurwitz
- Center for Global Health, University of New Mexico, Albuquerque, NM, United States
| | - Caroline Ndege
- University of New Mexico-Kenya Global Health Programs, Kisumu and Siaya, Kenya
| | - Elly Munde
- University of New Mexico-Kenya Global Health Programs, Kisumu and Siaya, Kenya,Department of Clinical Medicine, School of Health Science, Kirinyaga University, Kerugoya, Kenya
| | - Walter Otieno
- Department of Pediatrics and Child Health, School of Medicine, Maseno University, Maseno, Kenya
| | - Philip D. Seidenberg
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, United States
| | - Kristan A. Schneider
- Department Applied Computer and Bio-Sciences, University of Applied Sciences Mittweida, Mittweida, Germany
| | | | - Benjamin H. McMahon
- Theoretical Biology and Biophysics Group, Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM, United States
| | - Collins Ouma
- University of New Mexico-Kenya Global Health Programs, Kisumu and Siaya, Kenya,Department of Biomedical Sciences and Technology, School of Public Health and Community Development, Maseno University, Maseno, Kenya
| | - Douglas J. Perkins
- University of New Mexico-Kenya Global Health Programs, Kisumu and Siaya, Kenya,Center for Global Health, University of New Mexico, Albuquerque, NM, United States
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Irimu G, Aluvaala J, Malla L, Omoke S, Ogero M, Mbevi G, Waiyego M, Mwangi C, Were F, Gathara D, Agweyu A, Akech S, English M. Neonatal mortality in Kenyan hospitals: a multisite, retrospective, cohort study. BMJ Glob Health 2021; 6:e004475. [PMID: 34059493 PMCID: PMC8169483 DOI: 10.1136/bmjgh-2020-004475] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Most of the deaths among neonates in low-income and middle-income countries (LMICs) can be prevented through universal access to basic high-quality health services including essential facility-based inpatient care. However, poor routine data undermines data-informed efforts to monitor and promote improvements in the quality of newborn care across hospitals. METHODS Continuously collected routine patients' data from structured paper record forms for all admissions to newborn units (NBUs) from 16 purposively selected Kenyan public hospitals that are part of a clinical information network were analysed together with data from all paediatric admissions ages 0-13 years from 14 of these hospitals. Data are used to show the proportion of all admissions and deaths in the neonatal age group and examine morbidity and mortality patterns, stratified by birth weight, and their variation across hospitals. FINDINGS During the 354 hospital months study period, 90 222 patients were admitted to the 14 hospitals contributing NBU and general paediatric ward data. 46% of all the admissions were neonates (aged 0-28 days), but they accounted for 66% of the deaths in the age group 0-13 years. 41 657 inborn neonates were admitted in the NBUs across the 16 hospitals during the study period. 4266/41 657 died giving a crude mortality rate of 10.2% (95% CI 9.97% to 10.55%), with 60% of these deaths occurring on the first-day of admission. Intrapartum-related complications was the single most common diagnosis among the neonates with birth weight of 2000 g or more who died. A threefold variation in mortality across hospitals was observed for birth weight categories 1000-1499 g and 1500-1999 g. INTERPRETATION The high proportion of neonatal deaths in hospitals may reflect changing patterns of childhood mortality. Majority of newborns died of preventable causes (>95%). Despite availability of high-impact low-cost interventions, hospitals have high and very variable mortality proportions after stratification by birth weight.
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Affiliation(s)
- Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Jalemba Aluvaala
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Sylvia Omoke
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - George Mbevi
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Mary Waiyego
- Health Services, Nairobi Metropolitan Services, Nairobi, Kenya
| | - Caroline Mwangi
- Division of Neonatal and Child Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Fred Were
- Kenya Paediatric Research Consortium (KEPRECON), Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Ambrose Agweyu
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Oxford, Oxfordshire, UK
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Kiguba R, Karamagi C, Bird SM. Quality of care for adult in-patients with malaria in a tertiary hospital in Uganda. Malar J 2021; 20:178. [PMID: 33836769 PMCID: PMC8034187 DOI: 10.1186/s12936-021-03712-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 03/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prompt detection and appropriate treatment of malaria prevents severe disease and death. The quality of care for adult malaria in-patients is not well documented in sub-Saharan Africa, particularly in Uganda. The study sought to describe the patterns of malaria diagnosis and treatment among adult in-patients admitted to the medical and gynaecological wards of Uganda's 1790-bed Mulago National Referral Hospital from December 2013 to April 2014. METHODS A prospective cohort of 762 consented in-patients aged ≥ 18 years was assembled. Proportions of in-patients who received preadmission and in-hospital anti-malarials, missed Day 1 dosing of hospital-initiated anti-malarials and/or had malaria microscopy done were determined. Multivariable logistic regression was used to identify risk-factors for missed Day 1 dosing of anti-malarials. RESULTS One in five (19%, 146/762) in-patients had an admission or discharge malaria diagnosis or both; with median age of 29 years (IQR, 22-42 years). Microscopy was requested in 77% (108/141) of in-patients with an admission malaria diagnosis; results were available for 46% (50/108), of whom 42% (21/50) tested positive for Plasmodium falciparum malaria parasitaemia. Only 13% (11/83) of in-patients who received in-hospital injectable artesunate (AS) or quinine (Q) received follow-up oral artemether-lumefantrine (AL); 2 of 18 severe malaria cases received follow-up oral AL. Injectable AS only (47%, 47/100) was the most frequent hospital-initiated anti-malarial treatment followed by injectable Q only (23%, 23/100) amongst in-patients who received in-hospital anti-malarials. A quarter (25%, 25/100; 95% CI: 17-35%) of in-patients missed Day 1 dosing of hospital-initiated anti-malarials. Each additional admission diagnosis was more than two-fold likely to increase the odds of missed Day 1 dosing of in-hospital anti-malarials (aOR = 2.6, 95% CI: 1.52-4.56; P-value = 0.001). CONCLUSIONS Half the malaria microscopy results were not available; yet, the rate of testing was high. The majority of in-patients initiated on injectable AS or Q did not receive the recommended follow-up oral AL. One in four in-patients delayed to initiate hospital anti-malarials by at least one calendar day. The hospital should encourage prompt availability of malaria test-results to promote the timely initiation and completion of anti-malarial treatment, thereby improving the quality of care for hospitalized malaria patients in Uganda.
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Affiliation(s)
- Ronald Kiguba
- Department of Pharmacology and Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Charles Karamagi
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, Kampala, Uganda
| | - Sheila M Bird
- Medical Research Council Biostatistics Unit, Cambridge, UK
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English M, Irimu G, Akech S, Aluvaala J, Ogero M, Isaaka L, Malla L, Tuti T, Gathara D, Oliwa J, Agweyu A. Employing learning health system principles to advance research on severe neonatal and paediatric illness in Kenya. BMJ Glob Health 2021; 6:e005300. [PMID: 33758014 PMCID: PMC7993294 DOI: 10.1136/bmjgh-2021-005300] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 11/03/2022] Open
Abstract
We have worked to develop a Clinical Information Network (CIN) in Kenya as an early form of learning health systems (LHS) focused on paediatric and neonatal care that now spans 22 hospitals. CIN's aim was to examine important outcomes of hospitalisation at scale, identify and ultimately solve practical problems of service delivery, drive improvements in quality and test interventions. By including multiple routine settings in research, we aimed to promote generalisability of findings and demonstrate potential efficiencies derived from LHS. We illustrate the nature and range of research CIN has supported over the past 7 years as a form of LHS. Clinically, this has largely focused on common, serious paediatric illnesses such as pneumonia, malaria and diarrhoea with dehydration with recent extensions to neonatal illnesses. CIN also enables examination of the quality of care, for example that provided to children with severe malnutrition and the challenges encountered in routine settings in adopting simple technologies (pulse oximetry) and more advanced diagnostics (eg, Xpert MTB/RIF). Although regular feedback to hospitals has been associated with some improvements in quality data continue to highlight system challenges that undermine provision of basic, quality care (eg, poor access to blood glucose testing and routine microbiology). These challenges include those associated with increased mortality risk (eg, delays in blood transfusion). Using the same data the CIN platform has enabled conduct of randomised trials and supports malaria vaccine and most recently COVID-19 surveillance. Employing LHS principles has meant engaging front-line workers, clinical managers and national stakeholders throughout. Our experience suggests LHS can be developed in low and middle-income countries that efficiently enable contextually appropriate research and contribute to strengthening of health services and research systems.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Oxford Centre for Global Health Research, Nuffield Department of Clinical Medicine, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lynda Isaaka
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Timothy Tuti
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ambrose Agweyu
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
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9
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Ojo AA, Maxwell K, Oresanya O, Adaji J, Hamade P, Tibenderana JK, Abubakar SS, Audu BM, Njidda A, Gubio AB, Snow RW, Zurovac D. Health systems readiness and quality of inpatient malaria case-management in Kano State, Nigeria. Malar J 2020; 19:384. [PMID: 33126886 PMCID: PMC7602350 DOI: 10.1186/s12936-020-03449-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/16/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Nigeria was among the first African countries to adopt and implement change of treatment policy for severe malaria from quinine to artesunate. Seven years after the policy change health systems readiness and quality of inpatient malaria case-management practices were evaluated in Kano State of Nigeria. METHODS A cross-sectional survey was undertaken in May 2019 at all public hospitals. Data collection comprised hospital assessments, interviews with inpatient health workers and data extraction from medical files for all suspected malaria patients admitted to the paediatric and medical wards in April 2019. Descriptive analyses included 22 hospitals, 154 health workers and 1,807 suspected malaria admissions analysed from malaria test and treat case-management perspective. RESULTS 73% of hospitals provided malaria microscopy, 27% had rapid diagnostic tests and 23% were unable to perform any parasitological malaria diagnosis. Artemisinin-based combination therapy (ACT) was available at 96% of hospitals, artemether vials at 68% while injectable quinine and artesunate were equally stocked at 59% of hospitals. 32%, 21% and 15% of health workers had been exposed to relevant trainings, guidelines and supervision respectively. 47% of suspected malaria patients were tested while repeat testing was rare (7%). 60% of confirmed severe malaria patients were prescribed artesunate. Only 4% of admitted non-severe test positive cases were treated with ACT, while 76% of test negative patients were prescribed an anti-malarial. Artemether was the most common anti-malarial treatment for non-severe test positive (55%), test negative (43%) and patients not tested for malaria (45%). In all categories of the patients, except for confirmed severe cases, artemether was more commonly prescribed for adults compared to children. 44% of artesunate-treated patients were prescribed ACT follow-on treatment. Overall compliance with test and treat policy for malaria was 13%. CONCLUSIONS Translation of new treatment policy for severe malaria into inpatient practice is compromised by lack of malaria diagnostics, stock-outs of artesunate and suboptimal health workers' practices. Establishment of the effective supply chain and on-going supportive interventions for health workers accompanied with regular monitoring of the systems readiness and clinical practices are urgently needed.
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Affiliation(s)
| | | | | | | | | | | | | | - Bala M Audu
- National Malaria Elimination Programme, Abuja, Nigeria
| | - Ahmad Njidda
- National Malaria Elimination Programme, Abuja, Nigeria
| | | | - Robert W Snow
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya. .,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
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10
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Akech S, Chepkirui M, Ogero M, Agweyu A, Irimu G, English M, Snow RW. The Clinical Profile of Severe Pediatric Malaria in an Area Targeted for Routine RTS,S/AS01 Malaria Vaccination in Western Kenya. Clin Infect Dis 2020; 71:372-380. [PMID: 31504308 PMCID: PMC7353324 DOI: 10.1093/cid/ciz844] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/23/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The malaria prevalence has declined in western Kenya, resulting in the risk of neurological phenotypes in older children. This study investigates the clinical profile of pediatric malaria admissions ahead of the introduction of the RTS,S/AS01 vaccine. METHODS Malaria admissions in children aged 1 month to 15 years were identified from routine, standardized, inpatient clinical surveillance data collected between 2015 and 2018 from 4 hospitals in western Kenya. Malaria phenotypes were defined based on available data. RESULTS There were 5766 malaria admissions documented. The median age was 36 months (interquartile range, 18-60): 15% were aged between 1-11 months of age, 33% were aged 1-23 months of age, and 70% were aged 1 month to 5 years. At admission, 2340 (40.6%) children had severe malaria: 421/2208 (19.1%) had impaired consciousness, 665/2240 (29.7%) had an inability to drink or breastfeed, 317/2340 (13.6%) had experienced 2 or more convulsions, 1057/2340 (45.2%) had severe anemia, and 441/2239 (19.7%) had severe respiratory distress. Overall, 211 (3.7%) children admitted with malaria died; 163/211 (77% deaths, case fatality rate 7.0%) and 48/211 (23% deaths, case fatality rate 1.4%) met the criteria for severe malaria and nonsevere malaria at admission, respectively. The median age for fatal cases was 33 months (interquartile range, 12-72) and the case fatality rate was highest in those unconscious (44.4%). CONCLUSIONS Severe malaria in western Kenya is still predominantly seen among the younger pediatric age group and current interventions targeted for those <5 years are appropriate. However, there are increasing numbers of children older than 5 years admitted with malaria, and ongoing hospital surveillance would identify when interventions should target older children.
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Affiliation(s)
- Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mercy Chepkirui
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Morris Ogero
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Robert W Snow
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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11
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Gopal S, Ma Y, Xin C, Pitts J, Were L. Characterizing the Spatial Determinants and Prevention of Malaria in Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E5078. [PMID: 31842408 PMCID: PMC6950158 DOI: 10.3390/ijerph16245078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 11/26/2019] [Accepted: 12/05/2019] [Indexed: 01/19/2023]
Abstract
The United Nations' Sustainable Development Goal 3 is to ensure health and well-being for all at all ages with a specific target to end malaria by 2030. Aligned with this goal, the primary objective of this study is to determine the effectiveness of utilizing local spatial variations to uncover the statistical relationships between malaria incidence rate and environmental and behavioral factors across the counties of Kenya. Two data sources are used-Kenya Demographic and Health Surveys of 2000, 2005, 2010, and 2015, and the national Malaria Indicator Survey of 2015. The spatial analysis shows clustering of counties with high malaria incidence rate, or hot spots, in the Lake Victoria region and the east coastal area around Mombasa; there are significant clusters of counties with low incidence rate, or cold spot areas in Nairobi. We apply an analysis technique, geographically weighted regression, that helps to better model how environmental and social determinants are related to malaria incidence rate while accounting for the confounding effects of spatial non-stationarity. Some general patterns persist over the four years of observation. We establish that variables including rainfall, proximity to water, vegetation, and population density, show differential impacts on the incidence of malaria in Kenya. The El-Nino-southern oscillation (ENSO) event in 2015 was significant in driving up malaria in the southern region of Lake Victoria compared with prior time-periods. The applied spatial multivariate clustering analysis indicates the significance of social and behavioral survey responses. This study can help build a better spatially explicit predictive model for malaria in Kenya capturing the role and spatial distribution of environmental, social, behavioral, and other characteristics of the households.
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Affiliation(s)
- Sucharita Gopal
- Department of Earth & Environment, Boston University, Boston, MA 02215, USA; (S.G.); (Y.M.); (C.X.)
- Center for Global Development Policy, Boston University, Boston, MA 02215, USA;
| | - Yaxiong Ma
- Department of Earth & Environment, Boston University, Boston, MA 02215, USA; (S.G.); (Y.M.); (C.X.)
| | - Chen Xin
- Department of Earth & Environment, Boston University, Boston, MA 02215, USA; (S.G.); (Y.M.); (C.X.)
| | - Joshua Pitts
- Center for Global Development Policy, Boston University, Boston, MA 02215, USA;
| | - Lawrence Were
- College of Health & Rehabilitation Sciences: Sargent College, Boston University, Boston, MA 02215, USA
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12
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Nyaoke BA, Mureithi MW, Beynon C. Factors associated with treatment type of non-malarial febrile illnesses in under-fives at Kenyatta National Hospital in Nairobi, Kenya. PLoS One 2019; 14:e0217980. [PMID: 31194782 PMCID: PMC6563973 DOI: 10.1371/journal.pone.0217980] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 05/22/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Non-malarial febrile illnesses comprise of almost half of all fever presenting morbidities, among under-five children in sub-Saharan Africa. Studies have reported cases of prescription of antimalarial medications to these febrile under-fives who were negative for malaria. The treatment of these children with antimalarial medications increases incidences of antimalarial drug resistance as well as further morbidities and mortalities, due to failure to treat the actual underlying causes of fever. AIM To identify clinical and demographic factors associated with treatment type (malarial/non-malarial) of non-malarial febrile illnesses (NMFI) in children aged ≤5 at the Kenyatta National Hospital in Nairobi, Kenya. METHODS A positivist epistemological approach, cross sectional descriptive study design was used. A structured questionnaire was used on a sample of 341 medical records of children aged ≤5 years to extract data on clinical examinations (recorded as yes or no), diagnostic test results, and demographic data on the child's sex and age. Descriptive and inferential analysis was applied to the data. RESULTS Prescription of antimalarial drugs despite negative microscopy results was found in 44 (12.9%) of the children, with mortality reported in 48 (14.1%). Assessment of respiratory distress was 0.13 (0.03,0.58) times associated with less likelihood of prescribing an antimalarial in those with a negative microscopy. A male patient was 0.21 (0.05,0.89) times less likely to receive an intravenous antimalarial after a negative microscopy. Patients aged ˂1 with a negative microscopy result were more likely to receive an antimalarial than older children. CONCLUSION There is a need to eliminate incorrect treatment of NMFI with antimalarial medication, while ensuring correct diagnosis and treatment of the specific illness occurs. This requires strengthening and adherence to diagnostic and treatment guidelines of febrile illnesses in under-fives, consequently reducing morbidities and mortalities associated with inadequate management of NMFIs.
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Affiliation(s)
- Borna A. Nyaoke
- The University of Liverpool, Liverpool, United Kingdom
- The University of Nairobi, Nairobi, Kenya
- * E-mail:
| | | | - Caryl Beynon
- The University of Liverpool, Liverpool, United Kingdom
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13
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Elnour FA, Alagib MEA, Bansal D, Farag EABA, Malik EM. Severe malaria management: current situation, challenges and lessons learned from Gezira State, Sudan. Malar J 2019; 18:170. [PMID: 31088466 PMCID: PMC6515598 DOI: 10.1186/s12936-019-2805-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 05/07/2019] [Indexed: 12/19/2022] Open
Abstract
Background The present study aimed to evaluate the management of severe malaria at Gezira State hospitals in Sudan by assessing hospital readiness, health care provider knowledge and the care received by severe malaria patients. Methods A cross-sectional descriptive study was performed to assess the severe malaria management practices at hospitals level in Gezira State. The study population included hospitals, health care providers and patients. Data was collected using checklists and structured questionnaires. Results A total of 20 hospitals, 158 health care providers and 370 patients were included in the study. Out of the total hospitals, 95% (19/20) were providing 24 h outpatient services, 65% (13/20) had ICU units, while triage system was found in only 35% (7/20) of hospitals. From all hospitals evaluated, 90% (18/20) were suffering from shortage of staff, especially doctors. About half of the health care providers (46.7%) did not receive severe malaria management training. The average knowledge score among health care providers was 55.4%. Microscopy was available in all hospitals (100%), while rapid diagnostic test, complete blood count and renal function test were available in 15 hospitals (75%). Fever was the most presenting symptom (97.8%) followed by repeated vomiting (51.4%), convulsion in children (24.3%) and prostration in adult (57.9%). Correctly diagnosed patients were 68.9%. Essential tests were done for only 11.1% of patients. Majority of patients (91.7%) were treated with quinine, 5.9% received artemether, while 2.4% were treated with artemether–lumefantrine. Those who received both the correct dose and dosing regimen were 53.8%. The overall compliance to guidelines was 2.2%. Conclusion This study highlights the fact that management of severe malaria at hospital level was suboptimal with serious shortcomings in the different aspects of care particularly in specialized hospitals. Technical staff was inadequate, hospitals were anguish from defective emergency services, and most patients were not treated according to the national guidelines. Electronic supplementary material The online version of this article (10.1186/s12936-019-2805-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fahad A Elnour
- Communicable & Non Communicable Diseases Control Directorate, Federal Ministry of Health, Nile St, Khartoum, Sudan
| | - Mohammed E A Alagib
- Planning and International Health Directorate, Federal Ministry of Health, Nile St, Khartoum, Sudan
| | - Devendra Bansal
- Communicable Diseases Control Programmes, Public Health Department, Ministry of Public Health, Doha, Qatar
| | | | - Elfatih M Malik
- Planning and International Health Directorate, Federal Ministry of Health, Nile St, Khartoum, Sudan.
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Ayieko P, Irimu G, Ogero M, Mwaniki P, Malla L, Julius T, Chepkirui M, Mbevi G, Oliwa J, Agweyu A, Akech S, Were F, English M. Effect of enhancing audit and feedback on uptake of childhood pneumonia treatment policy in hospitals that are part of a clinical network: a cluster randomized trial. Implement Sci 2019; 14:20. [PMID: 30832678 PMCID: PMC6398235 DOI: 10.1186/s13012-019-0868-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 02/04/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) revised its clinical guidelines for management of childhood pneumonia in 2013. Significant delays have occurred during previous introductions of new guidelines into routine clinical practice in low- and middle-income countries (LMIC). We therefore examined whether providing enhanced audit and feedback as opposed to routine standard feedback might accelerate adoption of the new pneumonia guidelines by clinical teams within hospitals in a low-income setting. METHODS In this parallel group cluster randomized controlled trial, 12 hospitals were assigned to either enhanced feedback (n = 6 hospitals) or standard feedback (n = 6 hospitals) using restricted randomization. The standard (network) intervention delivered in both trial arms included support to improve collection and quality of patient data, provision of mentorship and team management training for pediatricians, peer-to-peer networking (meetings and social media), and multimodal (print, electronic) bimonthly hospital specific feedback reports on multiple indicators of evidence guideline adherence. In addition to this network intervention, the enhanced feedback group received a monthly hospital-specific feedback sheet targeting pneumonia indicators presented in multiple formats (graphical and text) linked to explicit performance goals and action plans and specific email follow up from a network coordinator. At the start of the trial, all hospitals received a standardized training on the new guidelines and printed booklets containing pneumonia treatment protocols. The primary outcome was the proportion of children admitted with indrawing and/or fast-breathing pneumonia who were correctly classified using new guidelines and received correct antibiotic treatment (oral amoxicillin) in the first 24 h. The secondary outcome was the proportion of correctly classified and treated children for whom clinicians changed treatment from oral amoxicillin to injectable antibiotics. RESULTS The trial included 2299 childhood pneumonia admissions, 1087 within the hospitals randomized to enhanced feedback intervention, and 1212 to standard feedback. The proportion of children who were correctly classified and treated in the first 24 h during the entire 9-month period was 38.2% (393 out of 1030) and 38.4% (410 out of 1068) in the enhanced feedback and standard feedback groups, respectively (odds ratio 1.11; 95% confidence interval [CI] 0.37-3.34; P = 0.855). However, in exploratory analyses, there was evidence of an interaction between type of feedback and duration (in months) since commencement of intervention, suggesting a difference in adoption of pneumonia policy over time in the enhanced compared to standard feedback arm (OR = 1.25, 95% CI 1.14 to 1.36, P < 0.001). CONCLUSIONS Enhanced feedback comprising increased frequency, clear messaging aligned with goal setting, and outreach from a coordinator did not lead to a significant overall effect on correct pneumonia classification and treatment during the 9-month trial. There appeared to be a significant effect of time (representing cumulative effect of feedback cycles) on adoption of the new policy in the enhanced feedback compared to standard feedback group. Future studies should plan for longer follow-up periods to confirm these findings. TRIAL REGISTRATION US National Institutes of Health-ClinicalTrials.gov identifier (NCT number) NCT02817971 . Registered September 28, 2016-retrospectively registered.
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Affiliation(s)
- Philip Ayieko
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul Mwaniki
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas Julius
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mercy Chepkirui
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - George Mbevi
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Fred Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Ampadu HH, Asante KP, Bosomprah S, Akakpo S, Hugo P, Gardarsdottir H, Leufkens HGM, Kajungu D, Dodoo ANO. Prescribing patterns and compliance with World Health Organization recommendations for the management of severe malaria: a modified cohort event monitoring study in public health facilities in Ghana and Uganda. Malar J 2019; 18:36. [PMID: 30736864 PMCID: PMC6368732 DOI: 10.1186/s12936-019-2670-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Injectable artesunate (AS) is the World Health Organization (WHO) recommended medication for the treatment of severe malaria followed with an oral artemisinin-based combination therapy (ACT). There are few studies indicating how physicians prescribe injectable AS, injectable quinine (Q) or injectable artemether (AR) and ACT for severe malaria. This study was undertaken to evaluate prescription compliance to the WHO recommendation in 8 public health facilities in Ghana and Uganda. This was a modified cohort event monitoring study involving patients who were administered with injectable anti-malarial for treatment of presumed or confirmed severe malaria. Patients prescribed at least one dose of injectable artesunate, artemether or quinine qualified to enrol in the study. Patients were recruited at inpatient facilities and followed up in the hospital, by phone or at home. Following WHO recommendations, patients are to be prescribed 3 doses of injectable AS, Q or AR for at least 24 h followed with oral ACT. Compliance rate was estimated as the number of patient prescriptions that met the WHO recommendation for treatment of severe malaria divided by the total number of patients who completed the study by end of follow up. Log-binomial regression model was used to identify predictors for compliance. Based on the literature and limitations of available data from the patients' record, the diagnosis results, age, gender, weight, and country were considered as potential predictors of prescriber adherence to the WHO recommendations. RESULTS A total of 1191 patients completed the study, of which 93% were prescribed injectable AS, 3.1% (injectable AR or Q) with 32.5% prescribed follow-on oral ACT and 26% on concomitant antibiotics. 391 (32.8%) were in Ghana and 800 (67.2%) in Uganda. There were 582 (48.9%) women. The median age was 3.9 years (IQR = 2, 9) and median weight was 13 kg (IQR = 10, 20). Of the 1191 patients, 329 of the prescriptions complied with the WHO recommendation (compliance rate = 27.6%; 95% CI = [25.2, 30.2]). Diagnostic results (Adjusted prevalence ratio (aPR) = 4.56; 95% = [3.42, 6.08]; p < 0.0001) and weight (20 + kg vs < 10 kg: aPR = 0.65; 95% = [0.44, 0.96]; p = 0.015) were identified as factors independently associated with compliance. CONCLUSION Injectable AS is the most commonly prescribed medicine in the management of severe malaria in Ghana and Uganda. However, adherence to the WHO recommendation of at least 3 doses of injectable anti-malarial in 24 h followed by a full course of ACT is low, at less than 30%.
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Affiliation(s)
- H Hilda Ampadu
- The African Collaborating Centre for Pharmacovigilance & Surveillance, Accra, Ghana. .,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands.
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Samuel Bosomprah
- Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana
| | | | - Pierre Hugo
- Medicines for Malaria Venture, Geneva, Switzerland
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, Division Laboratory and Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Dan Kajungu
- Makerere University Centre for Health and Population Research (MUCHAP), Iganga/Mayuge Health and Demographic Surveillance Site (IMHDSS), Kampala, Uganda
| | - Alexander N O Dodoo
- The African Collaborating Centre for Pharmacovigilance & Surveillance, Accra, Ghana
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Irimu G, Ogero M, Mbevi G, Agweyu A, Akech S, Julius T, Nyamai R, Githang’a D, Ayieko P, English M. Approaching quality improvement at scale: a learning health system approach in Kenya. Arch Dis Child 2018; 103. [PMID: 29514814 PMCID: PMC6278651 DOI: 10.1136/archdischild-2017-314348] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Grace Irimu
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - George Mbevi
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Ambrose Agweyu
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Samuel Akech
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Thomas Julius
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Rachel Nyamai
- Maternal, Newborn, Child and Adolescent Health Unit, Ministry of Health, Nairobi, Kenya
| | | | - Philip Ayieko
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Mike English
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Zurovac D, Machini B, Kiptui R, Memusi D, Amboko B, Kigen S, Njiri P, Waqo E. Monitoring health systems readiness and inpatient malaria case-management at Kenyan county hospitals. Malar J 2018; 17:213. [PMID: 29843717 PMCID: PMC5975267 DOI: 10.1186/s12936-018-2364-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/22/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Change of severe malaria treatment policy from quinine to artesunate, a major malaria control advance in Africa, is compromised by scarce data to monitor policy translation into practice. In Kenya, hospital surveys were implemented to monitor health systems readiness and inpatient malaria case-management. METHODS All 47 county referral hospitals were surveyed in February and October 2016. Data collection included hospital assessments, interviews with inpatient health workers and retrospective review of patients' admission files. Analysis included 185 and 182 health workers, and 1162 and 1224 patients admitted with suspected malaria, respectively, in all 47 hospitals. Cluster-adjusted comparisons of the performance indicators with exploratory stratifications were performed. RESULTS Malaria microscopy was universal during both surveys. Artesunate availability increased (63.8-85.1%), while retrospective stock-outs declined (46.8-19.2%). No significant changes were observed in the coverage of artesunate trained (42.2% vs 40.7%) and supervised health workers (8.7% vs 12.8%). The knowledge about treatment policy improved (73.5-85.7%; p = 0.002) while correct artesunate dosing knowledge increased for patients < 20 kg (42.7-64.6%; p < 0.001) and > 20 kg (70.3-80.8%; p = 0.052). Most patients were tested on admission (88.6% vs 92.1%; p = 0.080) while repeated malaria testing was low (5.2% vs 8.1%; p = 0.034). Artesunate treatment for confirmed severe malaria patients significantly increased (69.9-78.7%; p = 0.030). No changes were observed in artemether-lumefantrine treatment for non-severe test positive patients (8.0% vs 8.8%; p = 0.796). Among test negative patients, increased adherence to test results was observed for non-severe (68.6-78.0%; p = 0.063) but not for severe patients (59.1-62.1%; p = 0.673). Overall quality of malaria case-management improved (48.6-56.3%; p = 0.004), both for children (54.1-61.5%; p = 0.019) and adults (43.0-51.0%; p = 0.041), and in both high (51.1-58.1%; p = 0.024) and low malaria risk areas (47.5-56.0%; p = 0.029). CONCLUSION Most health systems and malaria case-management indicators improved during 2016. Gaps, often specific to different inpatient populations and risk areas, however remain and further programmatic interventions including close monitoring is needed to optimize policy translation.
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Affiliation(s)
- Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya. .,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Beatrice Machini
- National Malaria Control Programme, Ministry of Health, Nairobi, Kenya
| | - Rebecca Kiptui
- National Malaria Control Programme, Ministry of Health, Nairobi, Kenya
| | - Dorothy Memusi
- National Malaria Control Programme, Ministry of Health, Nairobi, Kenya
| | | | - Samuel Kigen
- National Malaria Control Programme, Ministry of Health, Nairobi, Kenya
| | | | - Ejersa Waqo
- National Malaria Control Programme, Ministry of Health, Nairobi, Kenya
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Prevalence, outcome and quality of care among children hospitalized with severe acute malnutrition in Kenyan hospitals: A multi-site observational study. PLoS One 2018; 13:e0197607. [PMID: 29771994 PMCID: PMC5957373 DOI: 10.1371/journal.pone.0197607] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 05/04/2018] [Indexed: 11/23/2022] Open
Abstract
Background Severe acute malnutrition (SAM) remains a major cause of admission and inpatient mortality worldwide in children aged less than 5 years. In this study, we explored SAM prevalence and outcomes in children admitted in 13 Kenyan hospitals participating in a Clinical Information Network (CIN). We also describe their immediate in-patient management. Methods We analyzed data for children aged 1–59 months collected retrospectively from medical records after discharge. Mean, median and ranges were used to summarize pooled and age-specific prevalence and mortality associated with SAM. Documentation of key signs and symptoms (S/S) and performance of indicators of quality of care for selected aspects of the WHO management steps were assessed. Logistic regression models were used to evaluate associations between documented S/S and mortality among SAM patients aged 6–59 months. Loess curves were used to explore performance change over time for indicators of selected SAM management steps. Results 5306/54140 (9.8%) children aged 1–59 months admitted with medical conditions in CIN hospitals between December 2013 and November 2016 had SAM. SAM prevalence identified by clinicians and case fatality varied widely across hospitals with median proportion (range) of 10.1% (4.6–18.2%) and 14.8% (6.0–28.6%) respectively. Seventeen variables were associated with increased mortality. Performance change over time of management steps varied across hospitals and across selected indicators but suggests some effect of regular audit and feedback. Conclusion Identification of SAM patients, their mortality and adherence to in-patient management recommendations varied across hospitals. An important group of SAM patients are aged less than 6 months. Continued efforts are required to improve management of SAM in routine settings as part of efforts to reduce inpatient mortality.
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Gachau S, Ayieko P, Gathara D, Mwaniki P, Ogero M, Akech S, Maina M, Agweyu A, Oliwa J, Oliwa J, Julius T, Malla L, Wafula J, Mbevi G, Irimu G, English M. Does audit and feedback improve the adoption of recommended practices? Evidence from a longitudinal observational study of an emerging clinical network in Kenya. BMJ Glob Health 2017; 2:e000468. [PMID: 29104769 PMCID: PMC5663259 DOI: 10.1136/bmjgh-2017-000468] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/08/2017] [Accepted: 09/18/2017] [Indexed: 11/21/2022] Open
Abstract
Background Audit and feedback (A&F) is widely used in healthcare but there are few examples of how to deploy it at scale in low-income countries. Establishing the Clinical Information Network (CIN) in Kenya provided an opportunity to examine the effect of A&F delivered as part of a wider set of activities to promote paediatric guideline adherence. Methods We analysed data collected from medical records on discharge for children aged 2–59 months from 14 Kenyan hospitals in the CIN. Hospitals joined CIN in phases and for each we analysed their initial 25 months of participation that occurred between December 2013 and March 2016. A total of 34 indicators of adherence to recommendations were selected for evaluation each classified by form of feedback (passive, active and none) and type of task (simple or difficult documentation and those requiring cognitive work). Performance change was explored graphically and using generalised linear mixed models with attention given to the effects of time and use of a standardised paediatric admission record (PAR) form. Results Data from 60 214 admissions were eligible for analysis. Adherence to recommendations across hospitals significantly improved for 24/34 indicators. Improvements were not obviously related to nature of feedback, may be related to task type and were related to PAR use in the case of documentation indicators. There was, however, marked variability in adoption and adherence to recommended practices across sites and indicators. Hospital-specific factors, low baseline performance and specific contextual changes appeared to influence the magnitude of change in specific cases. Conclusion Our observational data suggest some change in multiple indicators of adherence to recommendations (aspects of quality of care) can be achieved in low-resource hospitals using A&F and simple job aides in the context of a wider network approach.
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Affiliation(s)
- Susan Gachau
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Philip Ayieko
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - David Gathara
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul Mwaniki
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Morris Ogero
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Michuki Maina
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Jacqiue Oliwa
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Thomas Julius
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucas Malla
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James Wafula
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - George Mbevi
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya.,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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