Managing Neonatal and Early Childhood Syndromic Sepsis in Sub-District Hospitals in Resource Poor Settings: Improvement in Quality of Care through Introduction of a Package of Interventions in Rural Bangladesh

Enhancing emergency obstetric care navigation through a 'Welcome Person' model: insights from a health system strengthening initiative in Bangladesh

Background

Maternal mortality remains critical in Bangladesh, driven by delays in accessing timely care at health care facilities. Globally, a woman dies every two minutes from pregnancy or childbirth, often due to systemic inefficiencies in health care. In Bangladesh, high maternal mortality rates are worsened by overcrowded facilities, limited resources, and complex procedures. The 'three delays' model identifies barriers to care, with the third delay - receiving timely treatment - being a major contributor to maternal deaths. This study aims to generate evidence on how the 'Welcome Person' can improve maternity care at the facility level in Bangladesh.

Methods

We conducted a cross-sectional study from April to December 2022 among pregnant women at three selected health care facilities in Gaibandha District, Bangladesh. We deployed 20 'Welcome Persons' to navigate and assist pregnant women, enhancing maternal health care. The Welcome Persons provided round-the-clock support, guiding mothers from the moment they entered the hospital through their admission, treatment, and any necessary referrals. The Welcome Persons maintained detailed time-stamped records, tracking patient movements and service timelines.

Results

In this study of 5260 mothers, 47% presented with complications, with 52% arriving after office hours. The median time from entry to treatment was 15 minutes, with those without complications taking 14 minutes and those with complications 15 minutes. Entry-to-admission took a median of nine minutes, varying by age, with younger patients completing faster. Admission-to-treatment had a median time of six minutes, with severely complicated patients experiencing shorter times. Only 1% completed within five minutes, while 63% finished within 15 minutes. Upazila Health Complexes (UHCs) showed better performance in completing procedures within median times compared to the District Hospital (DH). Future study plans should include measuring maternal and neonatal outcomes as well.

Conclusions

This study demonstrates that timely maternal care is achievable by deploying a support person. Using the 'Welcome Person' model to address admission bottlenecks, health care facilities can enhance patient experiences and outcomes. Despite a few limitations, evidence generated from this study can be utilised for scaling up decisions and can contribute to the health policy.

Assessment of Facility Readiness for Pediatric Emergency and Critical Care Utilizing a 2-Phase Survey Conducted in Six Hospitals in Uganda and Cameroon: A Quality Improvement Study

OBJECTIVES

Each year, 5.3 million children under 5 years of age die in low-resource settings, often due to delayed recognition of disease severity, inadequate treatment, or a lack of supplies. We describe the use of a comprehensive digital facility-readiness survey tool, recently developed by the Pediatric Sepsis Data CoLaboratory, which aims to identify target areas for quality improvement related to pediatric emergency and critical care.

METHODS

Facility-readiness surveys were conducted at six sub-Saharan African hospitals providing pediatric emergency and critical care in Uganda (n = 4) and Cameroon (n = 2). The tool is a 2-phase survey to assess readiness to provide pediatric essential emergency and critical care: (1) an "environmental scan," focusing on infrastructure, availability, and functionality of resources, and (2) an "observational scan" assessing the quality and safety of care through direct observation of patients receiving treatment for common diseases. Data were captured in a mobile application and the findings analyzed descriptively.

RESULTS

Varying levels of facility readiness to provide pediatric emergency care were observed. Only 1 of 6 facilities had a qualified staff member to assess children for danger signs upon arrival, and only 2 of 6 had staff with skills to manage emergency conditions. Only 21% of essential medicines required for pediatric emergency and critical care were available at all six facilities. Most facilities had clean running water and soap or disinfectants, but most also experienced interruptions to their electricity supply. Less than half of patients received an appropriate discharge note and fewer received counseling on postdischarge care; follow-up was arranged in less than a quarter of cases.

CONCLUSIONS

These pilot findings indicate that facilities are partially equipped and ready to provide pediatric emergency and critical care. This facility-readiness tool can be utilized in low-resource settings to assist hospital administrators and policymakers to determine priority areas to improve quality of care for the critically ill child.

Assessing health systems' capacities to provide post-abortion care: insights from seven low- and middle-income countries

Background

Abortion-related complications significantly contribute to maternal morbidity and mortality globally. Post-abortion care (PAC) services are essential to safeguarding women's rights by substantially mitigating the health risks associated with abortions - a step which is fundamental to achieving reproductive and maternal health-related Sustainable Development Goals.

Methods

We conducted a secondary analysis of data from the nationally representative Service Provision Assessment (SPA) surveys conducted between 2015 and 2024 across three regions in seven low- and middle-income countries: Afghanistan, Bangladesh, Nepal, the Democratic Republic of Congo (DRC), Ethiopia, Senegal, and Haiti. We included 2951 primary facilities and 473 referral facilities offering normal delivery services. We used PAC signal functions to report capacity to provide basic and comprehensive PAC services in primary and referral facilities, respectively.

Results

Of all primary facilities offering normal delivery services, 50% in Afghanistan, 1% in Bangladesh, 8% in Nepal, 5% in DRC, 34% in Ethiopia, 38% in Senegal, and 19% in Haiti had the capacity to provide basic PAC services. Of the referral facilities, 47% in Afghanistan, 16% in Bangladesh, 50% in Nepal, 52% in DRC, 75% in Ethiopia, 46% in Senegal, and 32% in Haiti had the capacity to provide comprehensive PAC services. Primary facilities in Bangladesh, DRC, and Nepal had critical gaps in referral, ie, effective communication with referral centres and availability of a functional vehicle for emergency transportation. In referral facilities, 74% in Bangladesh and 59% in Nepal had the provision of blood transfusion. In terms of basic PAC services in primary facilities, the capacity of Senegal (from 16% in 2015 to 38% in 2019; P = 0.001) and Haiti (from 12% in 2013 to 19% in 2018; P = 0.007) increased, but the capacity of Bangladesh decreased (from 4% in 2014 to 1% in 2017; P = 0.016) over time.

Conclusions

There are substantial gaps in the capacity to provide basic and comprehensive PAC services in the selected countries. Investing in primary healthcare and improving communication and transportation should be the priority for enhancing basic PAC services, while strengthening referral hospitals to effectively handle emergencies and conduct major surgeries could significantly bolster their capacity to provide comprehensive PAC services.

Impact of neonatal sepsis on neurocognitive outcomes: a systematic review and meta-analysis

INTRODUCTION

Sepsis is associated with neurocognitive impairment among preterm neonates but less is known about term neonates with sepsis. This systematic review and meta-analysis aims to provide an update of neurocognitive outcomes including cognitive delay, visual impairment, auditory impairment, and cerebral palsy, among neonates with sepsis.

METHODS

We performed a systematic review of PubMed, Embase, CENTRAL and Web of Science for eligible studies published between January 2011 and March 2023. We included case-control, cohort studies and cross-sectional studies. Case reports and articles not in English language were excluded. Using the adjusted estimates, we performed random effects model meta-analysis to evaluate the risk of developing neurocognitive impairment among neonates with sepsis.

RESULTS

Of 7,909 studies, 24 studies (n = 121,645) were included. Majority of studies were conducted in the United States (n = 7, 29.2%), and all studies were performed among neonates. 17 (70.8%) studies provided follow-up till 30 months. Sepsis was associated with increased risk of cognitive delay [adjusted odds ratio, aOR 1.14 (95% CI: 1.01-1.28)], visual impairment [aOR 2.57 (95%CI: 1.14- 5.82)], hearing impairment [aOR 1.70 (95% CI: 1.02-2.81)] and cerebral palsy [aOR 2.48 (95% CI: 1.03-5.99)].

CONCLUSION

Neonates surviving sepsis are at a higher risk of poorer neurodevelopment. Current evidence is limited by significant heterogeneity across studies, lack of data related to long-term neurodevelopmental outcomes and term infants.

Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review

BACKGROUND

Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs.

METHODS

We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author.

RESULTS

We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change.

CONCLUSIONS

Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Challenges of Antibiotic Formulations and Administration in the Treatment of Bloodstream Infections in Children Under Five Admitted to Kisantu Hospital, Democratic Republic of Congo

Severe bacterial infections in children need prompt, appropriate antibiotic treatment. We report challenges observed within a prospective, cohort study on antibiotic efficacy in non-typhi Salmonella bloodstream infection (NCT04850677) in Kisantu district hospital (Democratic Republic of Congo). Children (aged > 28 days to < 5 years) admitted with suspected bloodstream infection (August 1, 2021 through July 31, 2022) were enrolled and followed until day 3 or discharge for non-typhi Salmonella patients. Antibiotics were administered to 98.4% (1,838/1,867) of children, accounting for 2,296 antibiotic regimens (95.7% intravenous, 4.3% oral). Only 78.3% and 61.8% of children were, respectively, prescribed and administered antibiotics on the admission day. At least one dose was not administered in 3.6% of children, mostly because of mismatch of the four times daily cefotaxime schedule with the twice-daily administration rounds. Inappropriate intravenous administration practices included multidose use, air-venting, and direct injection instead of perfusion. There was inaccurate aliquoting in 18.0% (32/178) of intravenous ciprofloxacin regimens, and thus administered doses were > 16% below the intended dose. Dosing accuracy of oral suspensions was impaired by lack of instructions for reconstitution, volume indicators, and/or dosing devices. Adult-dose tablets were split without/beyond scoring lines in 84.4% (27/32) of tablets. Poor availability and affordability of age-appropriate oral formulations contributed to low proportions of intravenous-to-oral switch (33.3% (79/237) of non-typhi Salmonella patients). Other quality issues included poor packaging, nonhomogeneous suspensions, and unsafe water for reconstitution. In conclusion, poor antibiotic products (no age-appropriate formulations, poor quality and access), processes (delayed prescription/administration, missed doses), and practices (inaccurate doses, [bio]safety risks) must be urgently addressed to improve pediatric antibiotic treatment.

Health services supervision in a protracted crisis: a qualitative study into supportive supervision practices in South Sudan

Background

The health system in South Sudan faces extreme domestic resource constraints, low capacity, and protracted humanitarian crises. Supportive supervision is believed to improve the quality of health care and service delivery by compensating for flaws in health workforce management. This study aimed to explore the current supervision practices in South Sudan and identify areas for quality improvement.

Methods

The study employed qualitative approaches to collect and analyse data from six purposefully selected counties. Data were collected from 194 participants using semi-structured interviews (43 health managers) and focus group discussions (151 health workers). Thematic content analysis was used to yield an in-depth understanding of the supervision practices in the health sector.

Results

The study found that integrated supportive supervision and monitoring visits were the main approaches used for health services supervision in South Sudan. Supportive supervision focused more on health system administration and less on clinical matters. Although fragmented, supportive supervision was carried out quarterly, while monitoring visits were either conducted monthly or ad hoc. Prioritization for supportive supervision was mainly data driven. Paper-based checklists were the most commonly used supervision tools. Many supervisors had no formal training on supportive supervision and only learned on the job. The health workers received on-site verbal feedback and, most times, on-the-job training sessions through coaching and mentorship. Action plans developed during supervision were inadequately followed up due to insufficient funding. Insecurity, poor road networks, lack of competent health managers, poor coordination, and lack of adequate means of transport were some of the challenges experienced during supervision. The presumed outcomes of supportive supervision were improvements in human resource management, drug management, health data reporting, teamwork, and staff respect for one another.

Conclusion

Supportive supervision remains a daunting task in the South Sudan health sector due to a combination of external and health system factors. Our study findings suggest that strengthening the processes and providing inputs for supervision should be prioritized if quality improvement is to be attained. This necessitates stronger stewardship from the Ministry of Health, integration of different supervision practices, investment in the capacity of the health workforce, and health infrastructure development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08637-4.

Newborn signal functions in Bangladesh: Identification through expert consultation and assessment of readiness among public health facilities

Background

This study aimed to identify a set of newborn signal functions (NSFs) that can categorize health facilities and assist policymakers and health managers in appropriately planning and adequately monitoring the progress and performance of health facilities delivering newborn health care in Bangladesh and similar low-income settings.

Methods

A modified Delphi method was used to identify a set of NSFs and a cross-sectional health facility assessment among the randomly selected facilities was conducted to test them in public health facilities in Bangladesh. In the modified Delphi approach, three main steps of listing, prioritizing, and testing were followed to identify the set of NSFs. Then, to finalize the set of NSFs and its variables, a total of five Delphi workshops and three rounds of Delphi surveys were conducted. Finally, 205 public health facilities located in 41 randomly selected districts were assessed for the availability and readiness of finalized NSFs using the updated tool of Bangladesh Health Facility Survey (BHFS) 2017.

Results

Twenty NSFs were identified and finalized, nine of which were categorized as primary NSFs, 13 as basic NSFs, 18 as comprehensive NSFs, and 20 as advanced NSFs. Almost all district hospitals (DHs), Upazila health complexes (UHCs,) and maternal and child welfare centres (MCWCs) performed the primary NSFs in the last three months. However, around one-third of the union health and family welfare centres (UH&FWCs) and very few community clinics (CCs) performed them during the same period. The basic, comprehensive, and advanced NSF readiness was inadequate and inappropriate across all types of facilities, including DHs and UHCs.

Conclusions

In the absence of internationally or nationally agreed-upon NSFs to measure a health facility's service availability and readiness for providing newborn care, this study becomes the first to identify and finalize a set of NSFs and to incorporate relevant variables in the health facility assessment tool which can be used to monitor the availability and readiness of a newborn care facility. The identified NSFs can also be adapted for the countries with similar contexts and can serve as a standard base to determine a global set of NSFs.

Neonatal Sepsis in a Resource-Limited Setting: Causative Microorganisms and Antimicrobial Susceptibility Profile

Background

Empiric treatment of suspected neonatal sepsis must be based on data on setting-specific causative pathogens and their respective susceptibilities to antimicrobials, as well as universal treatment guidelines. This approach will ensure better therapeutic outcomes and reduce mortality.

Objectives

The objectives of this study were to determine the bacteriological profile and antibiotic susceptibility pattern of isolated microorganisms responsible for neonatal sepsis in a regional hospital in Ghana.

Methods

This was a retrospective study that assessed causative microorganisms and antimicrobial susceptibility profiles of neonates suspected of sepsis at the Greater Accra Regional Hospital from January 2018 to December 2019. Blood culture was done using a fully automated BACTEC 9240 blood culture system. Bacteria isolates were identified by Gram staining and conventional biochemical methods. Antimicrobial susceptibility testing was done by Kirby–Bauer's disc diffusion method, and interpretations were carried out according to clinical and laboratory standards. Culture and antibiotic sensitivity reports were obtained and the data subsequently analyzed.

Results

Of 2514 blood samples collected from neonates suspected of neonatal sepsis, 528 (21.0%) of the samples were found to be culture-positive. The majority of these positive cultures were from male neonates (68.9%). A total of 11 different pathogens were isolated, of which Gram-positive organisms had a preponderance of 72.0% over Gram-negative organisms (28.0%). Staphylococcus epidermidis was the most common pathogen identified, accounting for 60.0% of isolates. The most prevalent Gram-negative bacteria were Klebsiella spp. (13.6%). Most Gram-positive microorganisms showed sensitivity to amikacin, meropenem, vancomycin, and piperacillin/tazobactam. Gram-positive isolates were found to be resistant to ampicillin and penicillin, but moderately susceptible to flucloxacillin. Most Gram-negative isolates were sensitive to meropenem.

Conclusion

The prevalence of culture-proven sepsis was 21.0%. The most prevalent Gram-negative bacteria were Klebsiella spp. As there is some level of antibiotic resistance observed in the current study, it is necessary for routine microbial analysis of samples and their antibiogram.

Introducing pulse oximetry in routine IMCI services in Bangladesh: A context-driven approach to influence policy and programme through stakeholder engagement

Background

An estimated 7 million episodes of severe newborn infections occur annually worldwide, with half a million newborn deaths, most occurring in low- and middle-income countries. Whilst injectable antibiotics are necessary to treat the infection, supportive care is also crucial in ending preventable mortality and morbidity. This study uses multi-country data to assess gaps in coverage, quality, and documentation of supportive care, considering implications for measurement.

Methods

The EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Newborns with an admission diagnosis of clinically-defined infection (sepsis, meningitis, and/or pneumonia) were included. Researchers extracted data from inpatient case notes and interviews with women (usually the mothers) as the primary family caretakers after discharge. The interviews were conducted using a structured survey questionnaire. We used descriptive statistics to report coverage of newborn supportive care components such as oxygen use, phototherapy, and appropriate feeding, and we assessed the validity of measurement through survey-reports using a random-effects model to generate pooled estimates. In this study, key supportive care components were assessment and correction of hypoxaemia, hyperbilirubinemia, and hypoglycaemia.

Results

Among 1015 neonates who met the inclusion criteria, 89% had an admission clinical diagnosis of sepsis. Major gaps in documentation and care practices related to supportive care varied substantially across the participating hospitals. The pooled sensitivity was low for the survey-reported oxygen use (47%; 95% confidence interval (CI) = 30%-64%) and moderate for phototherapy (60%; 95% CI = 44%-75%). The pooled specificity was high for both the survey-reported oxygen use (85%; 95% CI = 80%-89%) and phototherapy (91%; 95% CI = 82%-97%).

Conclusions

The women's reports during the exit survey consistently underestimated the coverage of supportive care components for managing infection. We have observed high variability in the inpatient documents across facilities. A standardised ward register for inpatient small and sick newborn care may capture selected supportive care data. However, tracking the detailed care will require standardised individual-level data sets linked to newborn case notes. We recommend investments in assessing the implementation aspects of a standardised inpatient register in resource-poor settings.

Multisystem Inflammatory Syndrome of a Neonate From a COVID-19-Infected Mother: A Case Report

In neonates, the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 - COVID-19) is lower. There is the potential for vertical transmission of SARS-CoV-2. To date, only a few reports suggest this possibility. Neonates usually have mild symptoms, but some develop multisystem involvement, which is a concern. COVID-19 infections have been reported both in pregnant women and their neonates. However, the evidence of vertical or horizontal transmission modes has not been fully established. We recorded a case study where a 33-year-old mother was tested positive for COVID-19 infection by RT-PCR during her 27^th week of gestation and needed ventilator support for her respiratory distress at that time for 11 days. Subsequently, she gave birth to a female baby at the 35^th week via a lower uterine segment cesarean section. The neonate manifested a severe multisystem inflammatory syndrome associated with her possible COVID-19 infection. Sharing her uncommon clinical presentation, immunological syndrome, and disease outcome are noteworthy for similar unforeseen pediatric case management to help guide future investigations and care.

Physical Quality of Life of Sepsis Survivor Severely Malnourished Children after Hospital Discharge: Findings from a Retrospective Chart Analysis

BACKGROUND

Quality of life (QoL) among pediatric sepsis survivors in resource-limited countries is poorly understood. We aimed to evaluate the QoL among sepsis survivors, by comparing them with non-sepsis survivors three months after hospital discharge.

METHODOLOGY

In this retrospective chart analysis with a case-control design, we compared children having sepsis and non-sepsis at hospital admission and during their post-hospitalization life, where the study population was derived from a hospital cohort of 405 severely malnourished children having pneumonia.

RESULTS

The median age (months, inter-quartile range) of the children having sepsis and non-sepsis was 10 (5, 17) and 9 (5, 18), respectively. Approximately half of the children among the sepsis survivors had new episodes of respiratory symptoms at home. Though death was significantly higher (15.8% vs. 2.7%, p ≤ 0.001) at admission among the sepsis group, deaths during post-hospitalization life (7.8% vs. 8.8%, p = 0.878) were comparable. A verbal autopsy revealed that before death, most of the children from the sepsis group had respiratory complaints, whereas gastrointestinal complaints were more common among the non-sepsis group.

CONCLUSIONS

Pediatric sepsis is life-threatening both during hospitalization and post-discharge. The QoL after sepsis is compromised, including re-hospitalization and the development of new episodes of respiratory symptoms especially before death.

Prevalence of hypoxaemia in children with pneumonia in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Pneumonia accounts for around 15% of all deaths of children younger than 5 years globally. Most happen in resource-constrained settings and are potentially preventable. Hypoxaemia is one of the strongest predictors of these deaths. We present an updated estimate of hypoxaemia prevalence among children with pneumonia in low-income and middle-income countries.

METHODS

We conducted a systematic review using the following key concepts "children under five years of age" AND "pneumonia" AND "hypoxaemia" AND "low- and middle-income countries" by searching in 11 bibliographic databases and citation indices. We included all articles published between Nov 1, 2008, and Oct 8, 2021, based on observational studies and control arms of randomised and non-randomised controlled trials. We excluded protocol papers, articles reporting hypoxaemia prevalence based on less than 100 pneumonia cases, and articles published before 2008 from the review. Quality appraisal was done with the Joanna Briggs Institute tools. We reported pooled prevalence of hypoxaemia (SpO2 <90%) by classification of clinical severity and by clinical settings by use of the random-effects meta-analysis models. We combined our estimate of the pooled prevalence of pneumonia with a previously published estimate of the number of children admitted to hospital due to pneumonia annually to calculate the total annual number of children admitted to hospital with hypoxaemic pneumonia.

FINDINGS

We identified 2825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, five from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI 26-36; 101 775 children) among all children with WHO-classified pneumonia, 41% (33-49; 30 483 children) among those with very severe or severe pneumonia, and 8% (3-16; 2395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than in studies conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% CI 5-8 million) were admitted to hospital with hypoxaemic pneumonia. The studies included in this systematic review had high τ2 (ie, 0·17), indicating a high level of heterogeneity between studies, and a high I2 value (ie, 99·6%), indicating that the heterogeneity was not due to chance. This study is registered with PROSPERO, CRD42019126207.

INTERPRETATION

The high prevalence of hypoxaemia among children with severe pneumonia, particularly among children who have been admitted to hospital, emphasises the importance of overall oxygen security within the health systems of low-income and middle-income countries, particularly in the context of the COVID-19 pandemic. Even among children with non-severe pneumonia that is managed in outpatient and community settings, the high prevalence emphasises the importance of rapid identification of hypoxaemia at the first point of contact and referral for appropriate oxygen therapy.

FUNDING

UK National Institute for Health Research (Global Health Research Unit on Respiratory Health [RESPIRE]; 16/136/109).

Epidemiology and Outcome of Sepsis in Adults and Children in a Rural, Sub-Sahara African Setting

Supplemental Digital Content is available in the text.

OBJECTIVES:

To identify the epidemiology and outcome of adults and children with and without sepsis in a rural sub-Sahara African setting.

DESIGN:

A priori planned substudy of a prospective, before-and-after trial.

SETTING:

Rural, sub-Sahara African hospital.

PATIENTS:

One-thousand four-hundred twelve patients (adults, n = 491; children, n = 921) who were admitted to hospital because of an acute infection.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Demographic, clinical, laboratory data, danger signs, and the presence of sepsis (defined as a quick Sequential Organ Failure Assessment score count ≥ 2) at admission were extracted. Sepsis was observed in 69 adults (14.1%) and 248 children (26.9%). Sepsis patients differed from subjects without sepsis in several demographic and clinical aspects. Malaria was the most frequent type of infection in adults (66.7%) and children (63.7%) with sepsis, followed by suspected bacterial and parasitic infections other than malaria. Adults with sepsis more frequently developed respiratory failure (8.7% vs 2.1%; p = 0.01), had a higher in-hospital mortality (17.4% vs 8.3%; p < 0.001), were less often discharged home (81.2% vs 92.2%; p = 0.007), and had higher median (interquartile range) costs of care (30,300 [19,400–49,900] vs 42,500 Rwandan Francs [27,000–64,400 Rwandan Francs]; p = 0.004) than adults without sepsis. Children with sepsis were less frequently discharged home than children without sepsis (93.1% vs 96.4%; p = 0.046). Malaria and respiratory tract infections claimed the highest absolute numbers of lives. The duration of symptoms before hospital admission did not differ between survivors and nonsurvivors in adults (72 [24–168] vs 96 hr [72–168 hr]; p = 0.27) or children (48 [24–72] vs 36 [24–108 hr]; p = 0.8). Respiratory failure and coma were the most common causes of in-hospital death.

CONCLUSIONS:

In addition to suspected bacterial, viral, and fungal infections, malaria and other parasitic infections are common and important causes of sepsis in adults and children admitted to a rural hospital in sub-Sahara Africa. The in-hospital mortality associated with sepsis is substantial, primarily in adults.

Nanotechnology as a Novel Approach in Combating Microbes Providing an Alternative to Antibiotics

The emergence of infectious diseases promises to be one of the leading mortality factors in the healthcare sector. Although several drugs are available on the market, newly found microorganisms carrying multidrug resistance (MDR) against which existing drugs cannot function effectively, giving rise to escalated antibiotic dosage therapies and the need to develop novel drugs, which require time, money, and manpower. Thus, the exploitation of antimicrobials has led to the production of MDR bacteria, and their prevalence and growth are a major concern. Novel approaches to prevent antimicrobial drug resistance are in practice. Nanotechnology-based innovation provides physicians and patients the opportunity to overcome the crisis of drug resistance. Nanoparticles have promising potential in the healthcare sector. Recently, nanoparticles have been designed to address pathogenic microorganisms. A multitude of processes that can vary with various traits, including size, morphology, electrical charge, and surface coatings, allow researchers to develop novel composite antimicrobial substances for use in different applications performing antimicrobial activities. The antimicrobial activity of inorganic and carbon-based nanoparticles can be applied to various research, medical, and industrial uses in the future and offer a solution to the crisis of antimicrobial resistance to traditional approaches. Metal-based nanoparticles have also been extensively studied for many biomedical applications. In addition to reduced size and selectivity for bacteria, metal-based nanoparticles have proven effective against pathogens listed as a priority, according to the World Health Organization (WHO). Moreover, antimicrobial studies of nanoparticles were carried out not only in vitro but in vivo as well in order to investigate their efficacy. In addition, nanomaterials provide numerous opportunities for infection prevention, diagnosis, treatment, and biofilm control. This study emphasizes the antimicrobial effects of nanoparticles and contrasts nanoparticles' with antibiotics' role in the fight against pathogenic microorganisms. Future prospects revolve around developing new strategies and products to prevent, control, and treat microbial infections in humans and other animals, including viral infections seen in the current pandemic scenarios.

Child mortality in Bangladesh - why, when, where and how? A national survey-based analysis

Background

Updated information on the cause of childhood mortality is essential for developing policies and designing programmes targeting the major burden of disease. There is a paucity of evidence regarding the current estimates of the cause of death in Bangladesh, which is essential for reinvigorating the current policies and reshaping existing strategies to avert preventable deaths. This paper aims to address this critical evidence gap and report the cause, timing and place of death among children under-five years of age using a nationally representative sample.

Methods

The present study was undertaken to provide updated estimates of causes of death among children under-five years of age using data from the 2017-18 round of the Bangladesh Demographic and Health Survey (BDHS). The verbal autopsy (VA) questionnaire of the 2017-18 BDHS was adapted from the standardised WHO 2016 instruments. Specially trained physicians reviewed the responses of the VA questionnaire and assigned the cause of death based on the online-2016-version of the International Classification of Diseases (ICD-10). We included 456 deaths among children under-five years of age in our analysis. Descriptive statistics were used to present the causes, timing and places of death with uncertainty ranges (UR).

Results

Pneumonia is the major killer (19%), accounting for approximately 24 268 (UR = 21 626-26 695) under-five deaths per-year. It is followed by birth asphyxia (16%), prematurity and low-birth-weight (11%), serious infections including sepsis (8%) causing 20 882 (UR = 18 608-22 970), 14 956 (UR = 13 327-16,452), and 10 723 (UR = 9555-11,795) deaths per-year, respectively. Drowning (8%) caused 10 441 (UR = 9304-11 485) deaths and congenital anomaly (7%) resulted in d 8748 (UR = 7795-9623) deaths per-year. Around 29% of all deaths occurred on the first day, 52% within the first week, and 66% within the first month of life. Around 70% of birth asphyxia, prematurity, and low birth weight-related deaths happen on the day of birth. Approximately 43% of pneumonia-related deaths occur in age 1-11 months, and around 51% of drowning-related deaths happen in age 12-23 months.

Conclusions

Pneumonia with other serious infections, birth asphyxia, prematurity and low-birth-weight are responsible for more than half of all deaths among children under-five years of age. Strengthening the existing maternal, neonatal and child health programmes may be helpful in averting the majority of these preventable deaths. A multisectoral approach is required for the prevention of childhood deaths, especially drowning-related fatalities. Special measures need to be taken to prevent and control emerging public health challenges like birth defects and congenital anomalies.

Hypoxaemia prevalence and its adverse clinical outcomes among children hospitalised with WHO-defined severe pneumonia in Bangladesh

Background

With an estimated 1 million cases per year, pneumonia accounts for 15% of all under-five deaths globally, and hypoxaemia is one of the strongest predictors of mortality. Most of these deaths are preventable and occur in low- and middle-income countries. Bangladesh is among the six high burden countries with an estimated 4 million pneumonia episodes annually. There is a gap in updated evidence on the prevalence of hypoxaemia among children with severe pneumonia in high burden countries, including Bangladesh.

Methods

We conducted a secondary analysis of data obtained from icddr,b-Dhaka Hospital, a secondary level referral hospital located in Dhaka, Bangladesh. We included 2646 children aged 2-59 months admitted with WHO-defined severe pneumonia during 2014-17. The primary outcome of interest was hypoxaemia, defined as SpO₂ < 90% on admission. The secondary outcome of interest was adverse clinical outcomes defined as deaths during hospital stay or referral to higher-level facilities due to clinical deterioration.

Results

On admission, the prevalence of hypoxaemia among children hospitalised with severe pneumonia was 40%. The odds of hypoxaemia were higher among females (adjusted Odds ratio AOR = 1.44; 95% confidence interval CI = 1.22-1.71) and those with a history of cough or difficulty in breathing for 0-48 hours before admission (AOR = 1.61; 95% CI = 1.28-2.02). Among all children with severe pneumonia, 6% died during the hospital stay, and 9% were referred to higher-level facilities due to clinical deterioration. Hypoxaemia was the strongest predictor of mortality (AOR = 11.08; 95% CI = 7.28-16.87) and referral (AOR = 5.94; 95% CI = 4.31-17) among other factors such as age, sex, history of fever and cough or difficulty in breathing, and severe acute malnutrition. Among those who survived, the median duration of hospital stay was 7 (IQR = 4-11) days in the hypoxaemic group and 6 (IQR = 4-9) days in the non-hypoxaemic group, and the difference was significant at P < 0.001.

Conclusions

The high burden of hypoxaemia and its clinical outcomes call for urgent attention to promote oxygen security in low resource settings like Bangladesh. The availability of pulse oximetry for rapid identification and an effective oxygen delivery system for immediate correction should be ensured for averting many preventable deaths.

Managing pneumonia through facility-based integrated management of childhood management (IMCI) services: an analysis of the service availability and readiness among public health facilities in Bangladesh

BACKGROUND

With an estimated 24,000 deaths per year, pneumonia is the single largest cause of death among young children in Bangladesh, accounting for 18% of all under-5 deaths. The Government of Bangladesh adopted the WHO recommended Integrated Management of Childhood Illness (IMCI)-strategy in 1998 for outpatient management of pneumonia, which was scaled-up nationally by 2014. This paper reports the service availability and readiness related to IMCI-based pneumonia management in Bangladesh. We conducted a secondary analysis of the Bangladesh Health Facility Survey-2017, which was conducted with a nationally representative sample including all administrative divisions and types of health facilities. We limited our analysis to District Hospitals (DHs), Maternal and Child Welfare Centres (MCWCs), Upazila (sub-district) Health Complexes (UHCs), and Union Health and Family Welfare Centres (UH&FWCs), which are mandated to provide IMCI services. Readiness was reported based on 10 items identified by national experts as 'essential' for pneumonia management.

RESULTS

More than 90% of DHs and UHCs, and three-fourths of UH&FWCs and MCWCs provide IMCI-based pneumonia management services. Less than two-third of the staff had ever received IMCI-based pneumonia training. Only one-third of the facilities had a functional ARI timer or a watch able to record seconds on the day of the visit. Pulse oximetry was available in 27% of the district hospitals, 18% of the UHCs and none of the UH&FWCs. Although more than 80% of the facilities had amoxicillin syrup or dispersible tablets, only 16% had injectable gentamicin. IMCI service registers were not available in nearly one-third of the facilities and monthly reporting forms were not available in around 10% of the facilities. Only 18% of facilities had a high-readiness (score 8-10), whereas 20% had a low-readiness (score 0-4). The readiness was significantly poorer among rural and lower level facilities (p < 0.001). Seventy-two percent of the UHCs had availability of one of any of the four oxygen sources (oxygen concentrators, filled oxygen cylinder with flowmeter, filled oxygen cylinder without flowmeter, and oxygen distribution system) followed by DHs (66%) and MCWCs (59%).

CONCLUSION

There are substantial gaps in the readiness related to IMCI-based pneumonia management in public health facilities in Bangladesh. Since pneumonia remains a major cause of child death nationally, Bangladesh should make a substantial effort in programme planning, implementation and monitoring to address these critical gaps to ensure better provision of essential care for children suffering from pneumonia.

Antibiotic use for inpatient newborn care with suspected infection: EN-BIRTH multi-country validation study

BACKGROUND

An estimated 30 million neonates require inpatient care annually, many with life-threatening infections. Appropriate antibiotic management is crucial, yet there is no routine measurement of coverage. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aimed to validate maternal and newborn indicators to inform measurement of coverage and quality of care. This paper reports validation of reported antibiotic coverage by exit survey of mothers for hospitalized newborns with clinically-defined infections, including sepsis, meningitis, and pneumonia.

METHODS

EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Neonates were included based on case definitions to focus on term/near-term, clinically-defined infection syndromes (sepsis, meningitis, and pneumonia), excluding major congenital abnormalities. Clinical management was abstracted from hospital inpatient case notes (verification) which was considered as the gold standard against which to validate accuracy of women's report. Exit surveys were conducted using questions similar to The Demographic and Health Surveys (DHS) approach for coverage of childhood pneumonia treatment. We compared survey-report to case note verified, pooled across the five sites using random effects meta-analysis.

RESULTS

A total of 1015 inpatient neonates admitted in the five hospitals met inclusion criteria with clinically-defined infection syndromes. According to case note verification, 96.7% received an injectable antibiotic, although only 14.5% of them received the recommended course of at least 7 days. Among women surveyed (n = 910), 98.8% (95% CI: 97.8-99.5%) correctly reported their baby was admitted to a neonatal ward. Only 47.1% (30.1-64.5%) reported their baby's diagnosis in terms of sepsis, meningitis, or pneumonia. Around three-quarters of women reported their baby received an injection whilst in hospital, but 12.3% reported the correct antibiotic name. Only 10.6% of the babies had a blood culture and less than 1% had a lumbar puncture.

CONCLUSIONS

Women's report during exit survey consistently underestimated the denominator (reporting the baby had an infection), and even more so the numerator (reporting known injectable antibiotics). Admission to the neonatal ward was accurately reported and may have potential as a contact point indicator for use in household surveys, similar to institutional births. Strengthening capacity and use of laboratory diagnostics including blood culture are essential to promote appropriate use of antibiotics. To track quality of neonatal infection management, we recommend using inpatient records to measure specifics, requiring more research on standardised inpatient records.

Risk factors and etiology of neonatal sepsis after hospital delivery: A case-control study in a tertiary care hospital of Rajshahi, Bangladesh

BACKGROUND

Sepsis is one of the major causes of neonatal death worldwide as well as in Bangladesh. The objective of the present study was to identify the risk factors and causative organisms of neonatal sepsis after delivery in a tertiary care hospital, Bangladesh.

METHODS

This was a case-control study conducted in the neonatal ward of Rajshahi Medical College Hospital (RMCH), a 1000-bed tertiary hospital situated in Rajshahi, Bangladesh. Neonates diagnosed as neonatal sepsis by clinical and laboratory parameters were included as cases in this study. Admitted neonates unsuspected or undiagnosed for sepsis were considered as controls. Maternal and neonatal information and their laboratory reports were collected and analyzed. Both bivariate and multiple logistic regression models were used to identify the risk factors of neonatal sepsis.

RESULTS

A total of 91 cases and 193 controls were included in the study. Maternal history of urinary tract infection (UTI) during the third trimester of pregnancy (aOR 2.75, 95% CI: 1.04-7.23, p <0.05), premature birth (aOR 2.77, 95% CI: 1.08-7.13, p <0.05) and APGAR score <7 at five minutes (aOR 2.58, 95% CI: 1.04-6.39, p <0.05) were associated with onset of neonatal sepsis in multiple logistic regression model. All these factors were also associated with developing early-onset neonatal sepsis, while maternal UTI and male sex of neonates were associated with developing late-onset neonatal sepsis. Escherichia coli (40.7%), Staphylococcus aureus (27.5%), and Klebsiella pneumoniae (18.7%) were the commonly isolated organisms causing neonatal sepsis. All these organisms were highly resistant to common antibiotics like amoxicillin, cephalosporins, aminoglycosides and quinolones. Carbapenemase group of drugs along with amikacin, nitrofurantoin and linezolid were the most sensitive drugs.

CONCLUSIONS

Strengthening the existing facility for antenatal screening for early diagnosis and treatment of maternal infection during pregnancy as well as identifying high-risk pregnancy for adequate perinatal management is necessary to prevent neonatal sepsis-related morbidity and mortality. Rational use of antibiotics according to local epidemiology and culture and sensitivity reports may minimize the increasing hazards of antibiotic resistance.

Newborn signal functions in Bangladesh: identification through expert consultation and assessment of readiness among public health facilities-study protocol using Delphi technique

INTRODUCTION

There is a set of globally accepted and nationally adapted signal functions for categorising health facilities for maternal services. Newborn resuscitation is the only newborn intervention which is included in the WHO recommended list of emergency obstetric care signal functions. This is not enough to comprehensively assess the readiness of a health facility for providing newborn services. In order to address the major causes of newborn death, the Government of Bangladesh has prioritised a set of newborn interventions for national scale-up, the majority of which are facility-based. Effective delivery of these interventions depends on a core set of functions (skills and services). However, there is no standardised and approved set of newborn signal functions (NSFs) based on which the service availability and readiness of a health facility can be assessed for providing newborn services. Thus, this study will be the first of its kind to identify such NSFs. These NSFs can categorise health facilities and assist policymakers and health managers to appropriately plan and adequately monitor the progress and performance of health facilities delivering newborn healthcare.

METHODS AND ANALYSIS

We will adopt the Delphi technique of consensus building for identification of NSFs and 1-2 indicator for each function while employing expert consultation from relevant experts in Bangladesh. Based on the identified NSFs and signal function indicators, the existing health facility assessment (HFA) tools will be updated, and an HFA survey will be conducted to assess service availability and readiness of public health facilities in relation to the new NSFs. Descriptive statistics (proportion) with a 95% CI will be used to report the level of service availability and readiness of public facilities regarding NSFs.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Research Review and Ethical Review Committee of icddr, b (PR-17089). Results will be disseminated through meetings, seminars, conference presentations and international peer-review journal articles.

Provider performance and facility readiness for managing infections in young infants in primary care facilities in rural Bangladesh

BACKGROUND

Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016.

METHODS

This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance.

RESULTS

At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7-57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens.

CONCLUSIONS

Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.

Prevalence and Factors Associated with Neonatal Sepsis in a Tertiary Hospital, North West Nigeria

CONTEXT

Neonatal sepsis is an important cause of morbidity and mortality of newborns, especially in developing countries.

AIMS

Our study determined the prevalence of neonatal sepsis and its predisposing factors among neonates admitted in Ahmadu Bello University Teaching Hospital (ABUTH).

SETTINGS AND DESIGN

This was a cross-sectional descriptive study conducted in ABUTH.

SUBJECTS AND METHODS

The data were abstracted from the case notes of neonates admitted from May 2017 to May 2018. A pretested pro forma was used to abstract the data.

STATISTICAL ANALYSIS USED

Odds ratios and multivariate logistic regression were used to determine the factors associated with neonatal sepsis among the study population.

RESULTS

The prevalence of neonatal sepsis was 37.6%. Escherichia coli was the most commonly isolated organism. Neonates 0-7 days of age were 2.8 times less likely to develop neonatal sepsis than older neonates. Babies born with an Apgar score of <6 within the 1st min were 2.4 times more likely to develop neonatal sepsis than those whose Apgar score was higher. Neonates of mothers who had urinary tract infection during pregnancy were 2.3 times more likely to have had sepsis and those whose mothers had premature rupture of membranes were 4.6 times more likely.

CONCLUSIONS

The prevalence of neonatal sepsis was high among the neonates studied. Neonatal and maternal factors were associated with sepsis in the neonates. These findings provide guidelines for the selection of empirical antimicrobial agents in the study site and suggest that a continued periodic evaluation is needed to anticipate the development of neonatal sepsis among neonates admitted.

The inability to walk unassisted at hospital admission as a valuable triage tool to predict hospital mortality in Rwandese patients with suspected infection

OBJECTIVE

To assess the value of the inability to walk unassisted to predict hospital mortality in patients with suspected infection in a resource-limited setting.

METHODS

This is a post hoc study of a prospective trial performed in rural Rwanda. Patients hospitalized because of a suspected acute infection and who were able to walk unassisted before this disease episode were included. At hospital presentation, the walking status was graded into: 1) can walk unassisted, 2) can walk assisted only, 3) cannot walk. Receiver operating characteristic (ROC) analyses and two-by-two tables were used to determine the sensitivity, specificity, negative and positive predictive values of the inability to walk unassisted to predict in-hospital death.

RESULTS

One-thousand-sixty-nine patients were included. Two-hundred-one (18.8%), 315 (29.5%), and 553 (51.7%) subjects could walk unassisted, walk assisted or not walk, respectively. Their hospital mortality was 0%, 3.8% and 6.3%, respectively. The inability to walk unassisted had a low specificity (20%) but was 100% sensitive (CI95%, 90-100%) to predict in-hospital death (p = 0.00007). The value of the inability to walk unassisted to predict in-hospital mortality (AUC ROC, 0.636; CI95%, 0.564-0.707) was comparable to that of the qSOFA score (AUC ROC, 0.622; CI95% 0.524-0.728). Fifteen (7.5%), 34 (10.8%) and 167 (30.2%) patients who could walk unassisted, walk assisted or not walk presented with a qSOFA score count ≥2 points, respectively (p<0.001). The inability to walk unassisted correlated with the presence of risk factors for death and danger signs, vital parameters, laboratory values, length of hospital stay, and costs of care.

CONCLUSIONS

Our results suggest that the inability to walk unassisted at hospital admission is a highly sensitive predictor of in-hospital mortality in Rwandese patients with a suspected acute infection. The walking status at hospital admission appears to be a crude indicator of disease severity.

Early implementation of guidelines for managing young infants with possible serious bacterial infection in Bangladesh

Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) with simpler antibiotic regimens if hospital referral is not feasible. Bangladesh was one of the first countries to adapt WHO guidance into national guidelines for implementation in primary healthcare facilities. Early implementation was led by the Ministry of Health and Family Welfare (MOHFW) in 10 subdistricts of Bangladesh with support from USAID's MaMoni Health System Strengthening project. This mixed methods implementation research case study explores programme feasibility and acceptability through analysis of service delivery data from 4590 sick young infants over a 15-month period, qualitative interviews with providers and MOHFW managers and documentation by project staff. Multistakeholder collaboration was key to ensuring facility readiness and feasibility of programme delivery. For the 514 (11%) infants classified as PSBI, provider adherence to prereferral treatment and follow-up varied across infection subcategories. Many clinical severe infection cases for whom referral was not feasible received the recommended two doses of injectable gentamicin and follow-up, suggesting delivery of simplified antibiotic treatment is feasible. However, prereferral antibiotic treatment was low for infants whose families accepted hospital referral, which highlights the need for additional focus on managing these cases in training and supervision. Systems for tracking sick infants that accept hospital referral are needed, and follow-up of all PSBI cases requires strengthening to ensure sick infants receive the recommended treatment, to monitor outcomes and assess the effectiveness of the programme. Only 11.2% (95% CI 10.3 to 12.1) of the expected PSBI cases sought care from the selected service delivery points in the programme period. However, increasing trends in utilisation suggest improved awareness and acceptability of services among families of young infants as the programme matured. Future programme activities should include interviews with caregivers to explore the complexities around referral feasibility and acceptability of simplified antibiotic treatment.

Effects of emergency obstetric care training on maternal and perinatal outcomes: a stepped wedge cluster randomised trial in South Africa

Introduction

Two-thirds of maternal deaths and 40% of intrapartum-related neonatal deaths are thought to be preventable through emergency obstetric and newborn care (EmOC&NC). The effectiveness of ‘skills and drills’ training of maternity staff in EmOC&NC was evaluated.

Methods

Implementation research using a stepped wedge cluster randomised trial including 127 of 129 healthcare facilities (HCFs) across the 11 districts in South Africa with the highest maternal mortality. The sequence in which all districts received EmOC&NC training was randomised but could not be blinded. The timing of training resulted in 10 districts providing data before and 10 providing data after EmOC&NC training. Primary outcome measures derived for HCFs are as follows: stillbirth rate (SBR), early neonatal death (ENND) rate, institutional maternal mortality ratio (iMMR) and direct obstetric case fatality rate (CFR), number of complications recognised and managed and CFR by complication.

Results

At baseline, median SBR (per 1000 births) and ENND rate (per 1000 live births) were 9 (IQR 0–28) and 0 (IQR 0–9). No significant changes following training in EmOC&NC were detected for any of the stated outcomes: SBR (adjusted incidence rate ratio (aIRR) 0.97, 95% CI 0.91 to 1.05), iMMR (aIRR 1.23, 95% CI 0.80 to 1.90), ENND rate (aIRR 1.04, 95% CI 0.92 to 1.17) and direct obstetric CFR (aIRR 1.15, 95% CI 0.66 to 2.02). The number of women who were recognised to need and received EmOC was significantly increased overall (aIRR 1.14, 95% CI 1.02 to 1.27), for haemorrhage (aIRR 1.31, 95% CI 1.13 to 1.52) and for postpartum sepsis (aIRR 1.86, 95% CI 1.17 to 2.95)

Conclusion

Following EmOC&NC training, healthcare providers are more able to recognise and manage complications at time of birth. This trial did not provide evidence that the intervention was effective in reducing adverse clinical outcomes, but demonstrates randomised evaluations are feasible in implementation research.

Trial registration number

ISRCTN11224105.

Supportive supervision to improve service delivery in low-income countries: is there a conceptual problem or a strategy problem?

Supportive supervision is perceived as an intervention that strengthens the health system, enables health workers to offer quality services and improve performance. Unfortunately, numerous studies show that supervisory mechanisms in many low-income countries (LICs) are suboptimal. Further, the understanding of the concept and its implementation is still shrouded in misinterpretations and inconsistencies. This analysis contributes to a deeper understanding of the concept of supportive supervision and how reorganisation of the approach can contribute to improved performance. The effectiveness of supportive supervision is mixed, with some studies noting that evidence on its role, especially in LICs is inconclusive. Quality of care is a core component of universal health coverage which, accentuates the need for supportive supervision. In the context of LICs, it is imperative for supportive supervision to be implemented as an on-going approach. Factors that affect supportive supervision encompass cultural, social, organizational and context dimensions but the capacity of majority of LIC to address these is limited. To this end, we underscore the need to review the supportive supervision approach to improve its effectiveness, and ensure that facility-based supervision embodies as many of the envisioned qualities as possible. We thus make a case for a stronger focus on internal supportive supervision where internal refers to health facility/unit/ward level. Inherent in the approach is what we refer to as ‘supervisee initiated supportive supervision’. The success of this approach must be anchored on a strong system for monitoring, data and information management at the health facility level.

Increasing Evidence-Based Interventions in Patients with Acute Infections in a Resource-Limited Setting: A Before-and-After Feasibility Trial in Gitwe, Rwanda

OBJECTIVE

To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections.

DESIGN

Single-center, prospective, before-and-after feasibility trial.

SETTING

Emergency department of a sub-Saharan African district hospital.

PATIENTS

Patients > 28 days of life admitted to the study hospital for an acute infection.

INTERVENTIONS

The trial had three phases (each of four months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases.

MEASUREMENTS AND MAIN RESULTS

Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 hours after hospital admission; and at discharge. A total of 1,594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 hours (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed.

CONCLUSIONS

Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population (www.clinicaltrials.gov: NCT02697513).

Early initiation of breastfeeding and severe illness in the early newborn period: An observational study in rural Bangladesh

BACKGROUND

In Bangladesh, neonatal sepsis is the cause of 24% of neonatal deaths, over 65% of which occur in the early-newborn stage (0-6 days). Only 50% of newborns in Bangladesh initiated breastfeeding within 1 hour of birth. The mechanism by which early initiation of breastfeeding reduces neonatal deaths is unclear, although the most likely pathway is by decreasing severe illnesses leading to sepsis. This study explores the effect of breastfeeding initiation time on early newborn danger signs and severe illness.

METHODS AND FINDINGS

We used data from a community-based trial in Bangladesh in which we enrolled pregnant women from 2013 through 2015 covering 30,646 newborns. Severe illness was defined using newborn danger signs reported by The Young Infants Clinical Science Study Group. We categorized the timing of initiation as within 1 hour, 1 to 24 hours, 24 to 48 hours, ≥48 hours of birth, and never breastfed. The analysis includes descriptive statistics, risk attribution, and multivariable mixed-effects logistic regression while adjusting for the clustering effects of the trial design, and maternal/infant characteristics. In total, 29,873 live births had information on breastfeeding among whom 19,914 (66.7%) initiated within 1 hour of birth, and 4,437 (14.8%) neonates had a severe illness by the seventh day after birth. The mean time to initiation was 3.8 hours (SD 16.6 hours). The proportion of children with severe illness increased as the delay in initiation increased from 1 hour (12.0%), 24 hours (15.7%), 48 hours (27.7%), and more than 48 hours (36.7%) after birth. These observations would correspond to a possible reduction by 15.9% (95% CI 13.2-25.9, p < 0.001) of severe illness in a real world population in which all newborns had breastfeeding initiated within 1 hour of birth. Children who initiated after 48 hours (odds ratio [OR] 4.13, 95% CI 3.48-4.89, p < 0.001) and children who never initiated (OR 4.77, 95% CI 3.52-6.47, p < 0.001) had the highest odds of having severe illness. The main limitation of this study is the potential for misclassification because of using mothers' report of newborn danger signs. There could be a potential for recall bias for mothers of newborns who died after being born alive.

CONCLUSIONS

Breastfeeding initiation within the first hour of birth is significantly associated with severe illness in the early newborn period. Interventions to promote early breastfeeding initiation should be tailored for populations in which newborns are delivered at home by unskilled attendants, the rate of low birth weight (LBW) is high, and postnatal care is limited.

TRIAL REGISTRATION

Trial Registration number: anzctr.org.au ID ACTRN12612000588897.

The effectiveness of training in emergency obstetric care: a systematic literature review

Providing quality emergency obstetric care (EmOC) reduces the risk of maternal and newborn mortality and morbidity. There is evidence that over 50% of maternal health programmes that result in improving access to EmOC and reduce maternal mortality have an EmOC training component. The objective was to review the evidence for the effectiveness of training in EmOC. Eleven databases and websites were searched for publications describing EmOC training evaluations between 1997 and 2017. Effectiveness was assessed at four levels: (1) participant reaction, (2) knowledge and skills, (3) change in behaviour and clinical practice and (4) availability of EmOC and health outcomes. Weighted means for change in knowledge and skills obtained, narrative synthesis of results for other levels. One hundred and one studies including before-after studies (n = 44) and randomized controlled trials (RCTs) (n = 15). Level 1 and/or 2 was assessed in 68 studies; Level 3 in 51, Level 4 in 21 studies. Only three studies assessed effectiveness at all four levels. Weighted mean scores pre-training, and change after training were 67.0% and 10.6% for knowledge (7750 participants) and 53.1% and 29.8% for skills (6054 participants; 13 studies). There is strong evidence for improved clinical practice (adherence to protocols, resuscitation technique, communication and team work) and improved neonatal outcomes (reduced trauma after shoulder dystocia, reduced number of babies with hypothermia and hypoxia). Evidence for a reduction in the number of cases of post-partum haemorrhage, case fatality rates, stillbirths and institutional maternal mortality is less strong. Short competency-based training in EmOC results in significant improvements in healthcare provider knowledge/skills and change in clinical practice. There is emerging evidence that this results in improved health outcomes.

Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols.  Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.

Increasing evidence-based interventions in patients with acute infections in a resource-limited setting: a before-and-after feasibility trial in Gitwe, Rwanda

OBJECTIVE

To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections.

DESIGN

Single-center, prospective, before-and-after feasibility trial.

SETTING

Emergency department of a sub-Saharan African district hospital.

PATIENTS

Patients > 28 days of life admitted to the study hospital for an acute infection.

INTERVENTIONS

The trial had three phases (each of 4 months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases.

MEASUREMENTS AND MAIN RESULTS

Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 h after hospital admission; and at discharge. A total of 1594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 h (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed.

CONCLUSIONS

Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population ( http://www.clinicaltrials.gov : NCT02697513).

Appropriate and timely antibiotic administration for neonatal sepsis in Mesoamérica

Neonatal sepsis is a leading cause of mortality among children under-5 in Latin America. The Salud Mesoamérica Initiative (SMI), a multicountry results-based aid programme, was designed to improve maternal, newborn and child health in impoverished communities in Mesoamérica. This study examines the delivery of timely and appropriate antibiotics for neonatal sepsis among facilities participating in the SMI project. A multifaceted health facility survey was implemented at SMI inception and approximately 18 months later as a follow-up. A random sample of medical records from neonates diagnosed with sepsis was reviewed, and data regarding antibiotic administration were extracted. In this paper, we present the percentage of patients who received timely (within 2 hours) and appropriate antibiotics. Multilevel logistic regression was used to assess for potential facility-level determinants of timely and appropriate antibiotic treatment. Among 821 neonates diagnosed with sepsis in 63 facilities, 61.8% received an appropriate antibiotic regimen, most commonly ampicillin plus an aminoglycoside. Within 2 hours of presentation, 32.3% received any antibiotic and only 26.6% received an appropriate regimen within that time. Antibiotic availability improved over the course of the SMI project, increasing from 27.5% at baseline to 64.0% at follow-up, and it was highly correlated with timely and appropriate antibiotic administration (adjusted OR=5.36, 95% CI 2.85 to 10.08). However, we also found a decline in the percentage of neonates documented to have received appropriate antibiotics (74.4% vs 51.1%). Our study demonstrated early success of the SMI project through improvements in the availability of appropriate antibiotic regimens for neonatal sepsis. At the same time, overall rates of timely and appropriate antibiotic administration remain low, and the next phase of the initiative will need to address other barriers to the provision of life-saving antibiotic treatment for neonatal sepsis.

Determinants of hardship financing in coping with out of pocket payment for care seeking of under five children in selected rural areas of Bangladesh

Background

Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship.

Objective

The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh.

Methods

A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted.

Results

A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household’s monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing.

Conclusion and policy implications

Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs.

Husband's involvement with mother's awareness and knowledge of newborn danger signs in facility-based childbirth settings: a cross-sectional study from rural Bangladesh

Objective

The aim of this study was to examine the association between husband involvement and maternal awareness and knowledge of newborn danger signs. This cross-sectional study was conducted in three rural hospitals of Bangladesh among the recently delivered women (RDW).

Results

RDW were interviewed to determine their knowledge and understanding of seven key neonatal danger signs. About 51.4% of the respondents were able to identify at least one danger sign. ‘Fever’ was the most correctly identified (43.7%), and hypothermia was the least (26.1%) identified danger sign. The factors associated with RDW possessing knowledge of at least one neonatal danger sign were: secondary education (COR: 1.3, 95% CI 1.1–1.6), increased ANC visits (COR: 1.2, 95% CI 1.1–1.3), previous history of facility delivery (COR: 1.3, 95% CI 1.1–1.4), and husband involvement in the mother’s facility delivery (COR: 1.3, 95% CI 1.1–1.5). RDW were more likely to recall at least one newborn danger sign (AOR: 1.2, 95% CI 1.1–1.4) when the husband was actively involved in his wife’s antenatal, delivery and postnatal care. In conclusion, this study found that husband involvement was significantly associated with the maternal knowledge related to identification of neonatal danger signs.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3386-6) contains supplementary material, which is available to authorized users.

Inhibition of necroptosis attenuates lung injury and improves survival in neonatal sepsis

BACKGROUND

Neonatal sepsis represents a unique therapeutic challenge owing to an immature immune system. Necroptosis is a form of programmed cell death that has been identified as an important mechanism of inflammation-induced cell death. Receptor-interacting protein kinase 1 plays a key role in mediating this process. We hypothesized that pharmacologic blockade of receptor-interacting protein kinase 1 activity would be protective in neonatal sepsis.

METHODS

Sepsis was induced in C57BL/6 mouse pups (5-7 days old) by intraperitoneal injection of adult cecal slurry. At 1 hour after cecal slurry injection, the receptor-interacting protein kinase 1 inhibitor necrostatin-1 (10 µg/g body weight) or vehicle (5% dimethyl sulfoxide in phosphate buffered saline) was administered via retro-orbital injection. At 20 hours after cecal slurry injection, blood and lung tissues were collected for various analyses.

RESULTS

At 20 hours after sepsis induction, vehicle-treated pups showed a marked increase in serum levels of interleukin 6, interleukin 1-beta, and interleukin 18 compared to sham. With necrostatin-1 treatment, serum levels of interleukin 6, interleukin 1-beta, and interleukin 18 were decreased by 77%, 81%, and 63%, respectively, compared to vehicle. In the lungs, sepsis induction resulted in a 232-, 10-, and 2.8-fold increase in interleukin 6, interleukin 1-beta, and interleukin 18 mRNA levels compared to sham, while necrostatin-1 treatment decreased these levels to 40-, 4-, and 0.8-fold, respectively. Expressions of the neutrophil chemokines keratinocyte chemoattractant and macrophage-inflammatory-protein-2 were also increased in the lungs in sepsis, while necrostatin-1 treatment decreased these levels by 81% and 61%, respectively, compared to vehicle. In addition, necrostatin-1 treatment significantly improved the lung histologic injury score and decreased lung apoptosis in septic pups. Finally, treatment with necrostatin-1 increased the 7-day survival rate from 0% in the vehicle-treated septic pups to 29% (P = .11).

CONCLUSION

Inhibition of receptor-interacting protein kinase 1 by necrostatin-1 decreases systemic and pulmonary inflammation, decreases lung injury, and increases survival in neonatal mice with sepsis. Targeting the necroptosis pathway might represent a new therapeutic strategy for neonatal sepsis.

Quality improvement initiatives for hospitalised small and sick newborns in low- and middle-income countries: a systematic review

BACKGROUND

An estimated 2.6 million newborns died in 2016; over 98.5% of deaths occurred in low- and middle-income countries (LMICs). Neonates born preterm and small for gestational age are particularly at risk given the high incidence of infectious complications, cardiopulmonary, and neurodevelopmental disorders in this group. Quality improvement (QI) initiatives can reduce the burden of mortality and morbidity for hospitalised newborns in these settings. We undertook a systematic review to synthesise evidence from LMICs on QI approaches used, outcome measures employed to estimate effects, and the nature of implementation challenges.

METHODS

We searched Medline, EMBASE, WHO Global Health Library, Cochrane Library, WHO ICTRP, and ClinicalTrials.gov and scanned the references of identified studies and systematic reviews. Searches covered January 2000 until April 2017. Search terms were "quality improvement", "newborns", "hospitalised", and their derivatives. Studies were excluded if they took place in high-income countries, did not include QI interventions, or did not include small and sick hospitalised newborns. Cochrane Risk of Bias tools were used to quality appraise the studies.

RESULTS

From 8110 results, 28 studies were included, covering 23 LMICs and 65,642 participants. Most interventions were meso level (district and clinic level); fewer were micro (patient-provider level) or macro (above district level). In-service training was the most common intervention subtype; service organisation and distribution of referencing materials were also frequently identified. The most commonly assessed outcome was mortality, followed by length of admission, sepsis rates, and infection rates. Key barriers to implementation of quality improvement initiatives included overburdened staff and lack of sufficient equipment.

CONCLUSIONS

The frequency of meso level, single centre, and educational interventions suggests that these interventions may be easier for programme planners to implement. The success of some interventions in reducing morbidity and mortality rates suggests that QI approaches have a high potential for benefit to newborns. Going forward, there are opportunities to strengthen the focus of QI initiatives and to develop improved, larger-scale, collaborative research into implementation of quality improvement initiatives for this high-risk group.

TRIAL REGISTRATION

PROSPERO CRD42017055459 .

Using geospatial techniques to develop an emergency referral transport system for suspected sepsis patients in Bangladesh

Background

A geographic information system (GIS)-based transport network within an emergency referral system can be the key to reducing health system delays and increasing the chances of survival, especially during an emergency. We employed a GIS to design an emergency transport system for the rapid transfer of pregnant or early post-partum women, newborns, and children under 5 years of age with suspected sepsis under the Interrupting Pathways to Sepsis Initiative (IPSI) project.

Methods

A GIS database was developed by mapping the villages, roads, and relevant physical features of the study area. A travel-time algorithm was developed to incorporate the time taken by different modes of local transport to reach the health complexes. These were used in a network analysis to identify the shortest routes to the hospitals from the villages, which were categorized into green, yellow, and red zones based on their proximity to the nearest hospitals to provide transport facilities. An emergency call-in centre established for the project managed the transport system, and its data was used to assess the uptake of this transport system amongst distant communities.

Results

Fifteen pre-existing and two new routes were identified as the shortest routes to the health complexes. The call-in centre personnel used this route information to direct both patients and transport drivers to the nearest transport hubs or pick-up points. Adherence with referral advice was high in areas where the IPSI transport operated. Over the study period, the utilisation of the project’s transport doubled and referral compliance from distant zones similarly increased.

Conclusions

The GIS system created for this study facilitated rapid referral of patients in emergency from distant zones, using locally available transport and resources. The methodology described in this study to develop and implement an emergency transport system can be applied in similar, rural, low-income country settings.

A Review on Antibiotic Resistance: Alarm Bells are Ringing

Antibiotics are the 'wonder drugs' to combat microbes. For decades, multiple varieties of antibiotics have not only been used for therapeutic purposes but practiced prophylactically across other industries such as agriculture and animal husbandry. Uncertainty has arisen, as microbes have become resistant to common antibiotics while the host remains unaware that antibiotic resistance has emerged. The aim of this review is to explore the origin, development, and the current state of antibiotic resistance, regulation, and challenges by examining available literature. We found that antibiotic resistance is increasing at an alarming rate. A growing list of infections i.e., pneumonia, tuberculosis, and gonorrhea are becoming harder and at times impossible to treat while antibiotics are becoming less effective. Antibiotic-resistant infections correlate with the level of antibiotic consumption. Non-judicial use of antibiotics is mostly responsible for making the microbes resistant. The antibiotic treatment repertoire for existing or emerging hard-to-treat multidrug-resistant bacterial infections is limited, resulting in high morbidity and mortality report. This review article reiterates the optimal use of antimicrobial medicines in human and animal health to reduce antibiotic resistance. Evidence from the literature suggests that the knowledge regarding antibiotic resistance in the population is still scarce. Therefore, the need of educating patients and the public is essential to fight against the antimicrobial resistance battle.

Application of Fluorescence In Situ Hybridization (FISH) Technique for the Detection of Genetic Aberration in Medical Science

Fluorescence in situ hybridization (FISH) is a macromolecule recognition technique, which is considered as a new advent in the field of cytology. Initially, it was developed as a physical mapping tool to delineate genes within chromosomes. The accuracy and versatility of FISH were subsequently capitalized upon in biological and medical research. This visually appealing technique provides an intermediate degree of resolution between DNA analysis and chromosomal investigations. FISH consists of a hybridizing DNA probe, which can be labeled directly or indirectly. In the case of direct labeling, fluorescent nucleotides are used, while indirect labeling is incorporated with reporter molecules that are subsequently detected by fluorescent antibodies or other affinity molecules. FISH is applied to detect genetic abnormalities that include different characteristic gene fusions or the presence of an abnormal number of chromosomes in a cell or loss of a chromosomal region or a whole chromosome. It is also applied in different research applications, such as gene mapping or the identification of novel oncogenes. This article reviews the concept of FISH, its application, and its advantages in medical science. 

An Association of Total Health Expenditure with GDP and Life Expectancy

Introduction: Gradual  total health expenditure (THE) has become a major concern. It is not only the increased THE, but also its unequal growth in  overall economy, found among the developing countries. If increased life expectancy is considered as a leverage for an individual’s investment in health services, it can be  expected that as the life expectancy increases, tendency of health care investment will also experience a boost up. Objective: The aim of the present study was to explore and identify the association of healthcare expenditure with the life expectancy and Gross Domestic Product (GDP) in developing countries, especially that of Bangladesh. Methodology: Data were retrospectively collected from “Health Bulletin 2011” and “Sample Vital Registration System 2010” of Bangladesh considering the fiscal year 1996 to fiscal year 2006. Using STATA, multivariable logistic regression was performed to find out the association of total health expenditure with GDP and life expectancy. Results: A direct relationship between GDP and total health expenditure was found through analysing the data. At the individual level, income  had a direct influence on health spending. However, there was no significant relationship between total health expenditure with increased life expectancy. Conclusion: The present study did not find any association between life expectancy and total health expenditure. However, our analysis found out that total health expenditure is more sensitive to gross domestic product rather than life expectancy.