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Conradi N, Opoka RO, Mian Q, Conroy AL, Hermann LL, Charles O, Amone J, Nabwire J, Lee BE, Saleh A, Mandhane P, Namasopo S, Hawkes MT. Solar-powered O 2 delivery for the treatment of children with hypoxaemia in Uganda: a stepped-wedge, cluster randomised controlled trial. Lancet 2024; 403:756-765. [PMID: 38367643 DOI: 10.1016/s0140-6736(23)02502-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND Supplemental O2 is not always available at health facilities in low-income and middle-income countries (LMICs). Solar-powered O2 delivery can overcome gaps in O2 access, generating O2 independent of grid electricity. We hypothesized that installation of solar-powered O2 systems on the paediatrics ward of rural Ugandan hospitals would lead to a reduction in mortality among hypoxaemic children. METHODS In this pragmatic, country-wide, stepped-wedge, cluster randomised controlled trial, solar-powered O2 systems (ie, photovoltaic cells, battery bank, and O2 concentrator) were sequentially installed at 20 rural health facilities in Uganda. Sites were selected for inclusion based on the following criteria: District Hospital or Health Centre IV with paediatric inpatient services; supplemental O2 on the paediatric ward was not available or was unreliable; and adequate space to install solar panels, a battery bank, and electrical wiring. Allocation concealment was achieved for sites up to 2 weeks before installation, but the study was not masked overall. Children younger than 5 years admitted to hospital with hypoxaemia and respiratory signs were included. The primary outcome was mortality within 48 h of detection of hypoxaemia. The statistical analysis used a linear mixed effects logistic regression model accounting for cluster as random effect and calendar time as fixed effect. The trial is registered at ClinicalTrials.gov, NCT03851783. FINDINGS Between June 28, 2019, and Nov 30, 2021, 2409 children were enrolled across 20 hospitals and, after exclusions, 2405 children were analysed. 964 children were enrolled before site randomisation and 1441 children were enrolled after site randomisation (intention to treat). There were 104 deaths, 91 of which occurred within 48 h of detection of hypoxaemia. The 48 h mortality was 49 (5·1%) of 964 children before randomisation and 42 (2·9%) of 1440 (one individual did not have vital status documented at 48 h) after randomisation (adjusted odds ratio 0·50, 95% CI 0·27-0·91, p=0·023). Results were sensitive to alternative parameterisations of the secular trend. There was a relative risk reduction of 48·7% (95% CI 8·5-71·5), and a number needed to treat with solar-powered O2 of 45 (95% CI 28-230) to save one life. Use of O2 increased from 484 (50·2%) of 964 children before randomisation to 1424 (98·8%) of 1441 children after randomisation (p<0·0001). Adverse events were similar before and after randomisation and were not considered to be related to the intervention. The estimated cost-effectiveness was US$25 (6-505) per disability-adjusted life-year saved. INTERPRETATION This stepped-wedge, cluster randomised controlled trial shows the mortality benefit of improving O2 access with solar-powered O2. This study could serve as a model for scale-up of solar-powered O2 as one solution to O2 insecurity in LMICs. FUNDING Grand Challenges Canada and The Women and Children's Health Research Institute.
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Affiliation(s)
- Nicholas Conradi
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda; Global Health Uganda, Kampala, Uganda
| | - Qaasim Mian
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Andrea L Conroy
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Olaro Charles
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jackson Amone
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | | | - Bonita E Lee
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Abdullah Saleh
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Piush Mandhane
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Sophie Namasopo
- Ministry of Health, Kabale, Uganda; Kabale Regional Referral Hospital, Kabale, Uganda
| | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada; School of Public Health, University of Alberta, Edmonton, AB, Canada; Stollery Science Lab, Edmonton, AB, Canada; Women and Children's Health Research Institute, Edmonton, AB, Canada.
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Mitran C, Opoka RO, Conroy AL, Namasopo S, Kain KC, Hawkes MT. Pediatric Malaria with Respiratory Distress: Prognostic Significance of Point-of-Care Lactate. Microorganisms 2023; 11:microorganisms11040923. [PMID: 37110346 PMCID: PMC10145304 DOI: 10.3390/microorganisms11040923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Respiratory distress (RD) in pediatric malaria portends a grave prognosis. Lactic acidosis is a biomarker of severe disease. We investigated whether lactate, measured at admission using a handheld device among children hospitalized with malaria and RD, was predictive of subsequent mortality. We performed a pooled analysis of Ugandan children under five years of age hospitalized with malaria and RD from three past studies. In total, 1324 children with malaria and RD (median age 1.4 years, 46% female) from 21 health facilities were included. Median lactate level at admission was 4.6 mmol/L (IQR 2.6–8.5) and 586 patients (44%) had hyperlactatemia (lactate > 5 mmol/L). The mortality was 84/1324 (6.3%). In a mixed-effects Cox proportional hazard model adjusting for age, sex, clinical severity score (fixed effects), study, and site (random effects), hyperlactatemia was associated with a 3-fold increased hazard of death (aHR 3.0, 95%CI 1.8–5.3, p < 0.0001). Delayed capillary refill time (τ = 0.14, p < 0.0001), hypotension (τ = −0.10, p = 0.00049), anemia (τ = −0.25, p < 0.0001), low tissue oxygen delivery (τ = −0.19, p < 0.0001), high parasite density (τ = 0.10, p < 0.0001), and acute kidney injury (p = 0.00047) were associated with higher lactate levels. In children with malaria and RD, bedside lactate may be a useful triage tool, predictive of mortality.
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Affiliation(s)
- Catherine Mitran
- Faculty of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala P.O. Box 7062, Uganda
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Sophie Namasopo
- Department of Paediatrics, Kabale District Hospital, Kabale P.O. Box 1102, Uganda
| | - Kevin C. Kain
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, ON M5G 1L7, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Michael T. Hawkes
- Department of Paediatrics, Faculty of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
- Department of Medical Microbiology and Immunology, Faculty of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
- School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada
- Stollery Science Lab, Edmonton, AB T6G 1C9, Canada
- Women and Children’s Health Research Institute, Edmonton, AB T6G 1C9, Canada
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Navuluri N, Srour ML, Kussin PS, Murdoch DM, MacIntyre NR, Que LG, Thielman NM, McCollum ED. Oxygen delivery systems for adults in Sub-Saharan Africa: A scoping review. J Glob Health 2021; 11:04018. [PMID: 34026051 PMCID: PMC8109278 DOI: 10.7189/jogh.11.04018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Respiratory diseases are the leading cause of death and disability worldwide. Oxygen is an essential medicine used to treat hypoxemia from respiratory diseases. However, the availability and utilization of oxygen delivery systems for adults in sub-Saharan Africa is not well-described. We aim to identify and describe existing data around oxygen availability and provision for adults in sub-Saharan Africa, determine knowledge or research gaps, and make recommendations for future research and capacity building. Methods We systematically searched four databases for articles on April 22, 2020, for variations of keywords related to oxygen with a focus on countries in sub-Saharan Africa. Inclusion criteria were studies that included adults and addressed hypoxemia assessment or outcome, oxygen delivery mechanisms, oxygen availability, oxygen provision infrastructure, and oxygen therapy and outcomes. Results 35 studies representing 22 countries met inclusion criteria. Availability of oxygen delivery systems ranged from 42%-94% between facilities, with wide variability in the consistency of availability. There was also wide reported prevalence of hypoxemia, with most studies focusing on specific populations. In facilities where oxygen is available, health care workers are ill-equipped to identify adult patients with hypoxemia, provide oxygen to those who need it, and titrate or discontinue oxygen appropriately. Oxygen concentrators were shown to be the most cost-effective delivery system in areas where power is readily available. Conclusions There is a substantial need for building capacity for oxygen delivery throughout sub-Saharan Africa. Addressing this critical issue will require innovation and a multi-faceted approach of developing infrastructure, better equipping facilities, and health care worker training.
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Affiliation(s)
- Neelima Navuluri
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Maria L Srour
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Peter S Kussin
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - David M Murdoch
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Neil R MacIntyre
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Loretta G Que
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA.,Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Stein F, Perry M, Banda G, Woolhouse M, Mutapi F. Oxygen provision to fight COVID-19 in sub-Saharan Africa. BMJ Glob Health 2020; 5:bmjgh-2020-002786. [PMID: 32532759 PMCID: PMC7295423 DOI: 10.1136/bmjgh-2020-002786] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 01/08/2023] Open
Affiliation(s)
- Felix Stein
- NIHR Global Health Research Unit Tackling Infections to Benefit Africa (TIBA), University of Edinburgh, Edinburgh, UK .,Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Meghan Perry
- Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Geoffrey Banda
- NIHR Global Health Research Unit Tackling Infections to Benefit Africa (TIBA), University of Edinburgh, Edinburgh, UK.,The Innogen Institute, University of Edinburgh, Science Technology and Innovation Studies, Edinburgh, UK
| | - Mark Woolhouse
- NIHR Global Health Research Unit Tackling Infections to Benefit Africa (TIBA), University of Edinburgh, Edinburgh, UK.,Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Francisca Mutapi
- NIHR Global Health Research Unit Tackling Infections to Benefit Africa (TIBA), University of Edinburgh, Edinburgh, UK.,Institute of Immunology and Infection Research, University of Edinburgh, Edinburgh, UK
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