Hepatitis B virus and other transfusion-transmissible infections in child blood recipients in Lao People's Democratic Republic: a hospital-based study

INTRODUCTION

Children requiring multiple blood transfusions are at high risk of transfusion-transmissible infections (TTIs). Lao People's Democratic Republic is a low-resource setting where donor blood screening faces challenges. This study aimed to determine the burden of TTIs in children in Vientiane Capital.

METHODS

300 children with transfusion history and 300 controls were recruited. In addition, 49 newly diagnosed transfusion recipients were followed for up to 12 months. Serum was tested for hepatitis B surface antigen and IgG antibodies against parvovirus B19, hepatitis B, C and E viruses.

RESULTS

The patients had a similar prevalence of anti-hepatitis B core antibodies (56; 18.7%) and hepatitis B surface antigen (8; 2.7%) as the controls (58; 19.3% and 9; 3.0%, respectively). However, there was a higher prevalence of an antibody profile suggestive of hepatitis B vaccination (anti-hepatitis B surface antibody positive/anti-hepatitis B core antibody negative) in the transfused group (140/299; 46.8%) than in controls (77/300; 25.7%, p<0.01). All other markers were similar in the patients and controls or higher in the controls: anti-hepatitis C virus (2.7% and 3.3%, p=0.6), anti-hepatitis E virus (7.5% and 12.7%, p=0.006) and anti-parvovirus B19 (2.4% and 8.5%, p=0.001). The longitudinal cohort did not show an increase in any marker over time.

CONCLUSION

Our results suggest no significant role of TTIs in Lao children. The higher prevalence of the hepatitis B vaccination profile in transfusion recipients showed that recommendations to vaccinate before commencing transfusions is at least partially implemented, although there is room for improvement.

Epidemiology of acute respiratory viral infections in children in Vientiane, Lao People's Democratic Republic

Respiratory infections are one of the most frequent reasons for medical consultations in children. In low resource settings such as in Lao People's Democratic Republic, knowledge gaps and the dearth of laboratory capacity to support differential diagnosis may contribute to antibiotic overuse. We studied the etiology, temporal trends, and genetic diversity of viral respiratory infections in children to provide evidence for prevention and treatment guidelines. From September 2014 to October 2015, throat swabs and nasopharyngeal aspirates from 445 children under 10 years old with symptoms of acute respiratory infection were collected at the Children Hospital in Vientiane. Rapid antigen tests were performed for influenza A and B and respiratory syncytial virus. Real-time reverse-transcription polymerase chain reactions (RT-PCRs) were performed to detect 16 viruses. Influenza infections were detected with a higher sensitivity using PCR than with the rapid antigen test. By RT-PCR screening, at least one pathogen could be identified for 71.7% of cases. Human rhinoviruses were most frequently detected (29.9%), followed by influenza A and B viruses combined (15.9%). We identify and discuss the seasonality of some of the infections. Altogether these data provide a detailed characterization of respiratory pathogens in Lao children and we provide recommendations for vaccination and further studies.

Timeliness of immunisation with the pentavalent vaccine at different levels of the health care system in the Lao People's Democratic Republic: A cross-sectional study

Background

The timely administration of vaccines is considered to be important for both individual and herd immunity. In this study, we investigated the timeliness of the diphtheria-tetanus-whole cell pertussis-hepatitis B-Haemophilus influenzae type b (pentavalent) vaccine, scheduled at 6, 10 and 14 weeks of age in the Lao People’s Democratic Republic. We also investigated factors associated with delayed immunization.

Methods

1162 children aged 8–28 months who had received the full course of the pentavalent vaccine at different levels of the health care system were enrolled. Vaccination dates documented in hospital records and/or immunisation cards were recorded. Age at vaccination and time intervals between doses were calculated. Predictors for timely completion with the pentavalent vaccine at 24 weeks were assessed by bivariate and multivariable analyses.

Results

Several discrepancies in dates between vaccination documents were observed. In general, vaccination with the pentavalent vaccine was found to be delayed, especially in health care settings below the provincial hospital level. Compared to the central hospital level, less participants who were vaccinated at the district/health center level received the third dose by 16 (48% at the central hospital level vs. 7.1% at the district and 12.4% at the health center level) and 24 weeks of age (94.4% at the central hospital level vs 64.6% at the district-outreach and 57.4% at the health center level) respectively. In logistic regression analyses, lower education level of the mother as well as vaccination by outreach service, were independently associated with delayed completion of vaccination.

Conclusion

We observed a general delay of vaccination, especially at lower ranked facilities, which correlated with indicators of poor access to health services. This highlights the need for further improving health equity in rural areas. Age-appropriate vaccination should become a quality indicator for the national immunization programme. In addition, we recommend further training of the health care staff regarding the importance of reliable documentation of dates.

Seroprotection at Different Levels of the Healthcare System After Routine Vaccination With Diphtheria-Tetanus-Pertussis whole cell-Hepatitis B-Haemophilus influenzae Type B in Lao People's Democratic Republic

Background

The Lao People’s Democratic Republic continues to sustain a considerable burden of vaccine-preventable diseases because of incomplete vaccine coverage and weak vaccine responses. We have assessed seroconversion after routine vaccination with the pentavalent vaccine to capture weaknesses of vaccine management at the different levels of the healthcare system.

Methods

A total of 1151 children (aged 8–28 months) with 3 documented doses of the pentavalent vaccine delivered at central hospitals in Vientiane and the provincial hospital, 3 district hospitals, and 10 health centers in Bolikhamxay province were enrolled. Sociodemographic information was collected with a standardized questionnaire. Serum samples were analyzed for antibodies against vaccine components, and bivariate and multivariable analyses were performed to identify risk factors for low vaccine responses.

Results

Seroprotection rates at the provincial, district, and health center level were as high as in central hospitals, but seroprotection rates in areas covered by remote health centers were significantly lower. Protective levels also rapidly decreased with age at sampling. Seroprotection rates in Bolikhamxay against the different components reached 70%–77% and were up to 20% higher than in previous studies in the same region; 18.8% more children received the hepatitis B vaccine birth dose and the hepatitis B virus infection rate was 4 times lower.

Conclusions

Vaccine immunogenicity has dramatically improved in a central province, likely due to training and investment in the cold chain. Nevertheless, there remains a need to focus on the “last mile” in remote areas were most children are vaccinated through outreach activities.

Congenital heart disease at Laos Children's Hospital: Two year experience

BACKGROUND

Management of congenital heart disease (CHD) in developing countries is challenging because of limited access to health-care facilities and socioeconomic limitations. The aim of this study was to describe the recent experience with CHD at Children's Hospital, Vientiane, Laos, the only pediatric referral hospital in the country.

METHODS

From July 2013 to November 2015, 1009 echocardiograms were carried out in 797 individuals who visited Children's Hospital, in whom CHD was identified in 213. Demographic characteristics, echocardiography and age at first CHD diagnosis on echocardiogram were compared by residential area.

RESULTS

Among the 213 patients, the most frequent anomalies, in descending order, were ventricular septal defect, atrial septal defect, patent ductus arteriosus, and tetralogy of Fallot. Moderate or severe CHD requiring surgery or intervention was detected in 137 patients; median age at initial diagnosis was 6.0 months (IQR, 1.5-29.8). Among those with moderate or severe CHD, 89 patients were from rural areas and 48 from the capital area. The proportion of patients from rural areas older than 1 and 3 years at diagnosis was 46.1% and 32.6%, respectively. In contrast, patients from the capital area were diagnosed at a significantly earlier age: 16.7% at age >1 year and 6.2% at age >3 years (both P < 0.001 vs rural areas).

CONCLUSIONS

Diagnosis of CHD requiring surgery is delayed in Laos, especially in rural areas. Better education and training of local medical staff, and greater access to medical advice are required to improve CHD care in Laos.

The first picture archiving and communication system in Lao People's Democratic Republic: Changes in the utilization rate of imaging tests in the first year after implementation

BACKGROUND

Implementation of the Picture Archiving and Communication System (PACS) is more challenging in developing countries than in developed countries. Given that the first PACS in Lao People's Democratic Republic (PDR) was successfully installed at the Children's Hospital of Lao PDR, we aimed to investigate whether the utilization rate of imaging tests increased after PACS implementation.

METHODS

PACS was implemented at the Children's Hospital of Lao PDR in December 2014. We compared the utilization rates of imaging tests including X-ray and ultrasound examinations between the pre-PACS period (from December 2013 to November 2014) and the post-PACS period (from December 2014 to November 2015). The utilization rate was defined as the number of imaging tests divided by the number of patients per month.

RESULTS

The average number of total imaging tests was 225.8/month (standard deviation [SD], 37.7) during the 1-year pre-PACS period and was 269.4/month (SD, 38.5) during the 1-year post-PACS period (P=0.0103). The utilization rate of total imaging tests significantly increased after PACS implementation (pre-PACS, 2.47%/month; post-PACS, 4.23%/month; P<0.0001). Increased utilization rates were observed for both X-rays (pre-PACS, 1.65%/month; post-PACS, 2.38%/month; P=0.0004) and ultrasound examinations (pre-PACS, 0.82%/month; post-PACS, 1.85%/month; P=0.0001).

CONCLUSIONS

The implementation of PACS at the Children's Hospital of Lao PDR resulted in a significant increase in the utilization rate of imaging tests, suggesting the indirect benefit of improved quality of care. Our findings showed that the benefits of PACS can be realized even in a resource-limited country such as Lao PDR.

Antenatal education for expectant mothers results in sustained improvement in knowledge of newborn care

OBJECTIVE

Basic perinatal education to increase parental knowledge of neonatal illnesses (such as respiratory distress, sepsis, complications of prematurity) could be a feasible way to reduce high neonatal mortality rates in limited-resource nurseries. To assess the efficacy of antenatal education in increasing mothers' knowledge of basic newborn care in a limited-resource nursery, and to determine whether the knowledge is retained postpartum.

STUDY DESIGN

In March to April 2008, we implemented a 10-min educational program on basic neonatal care for women receiving prenatal care in a maternal child hospital in Vientiane, Laos. The educational intervention was a structured, face-to-face interactive module taught by Lao providers using pictographic and written materials about temperature control, umbilical cord care and signs of neonatal illness. We assessed knowledge before and immediately after the module using a standardized interview tool. When possible, we reassessed knowledge postpartum to determine whether they retained information after the training.

RESULT

We recruited 101 women (average age=26.3 years), and the majority (53%) were primigravidas. Participants were well educated by local standards; 57% of women had >8 years and 28% had >12 years of education. Women's knowledge of neonatal care increased by 10% on immediate posttest (P<0.0001), especially regarding knowledge of umbilical cord care and temperature control (normal temperature ranges, thermometer use). Maternal education (P=0.025) and previous births (P=0.037) correlated positively with higher pretest scores. Higher maternal education correlated with higher posttest scores (P=0.01); however, less-educated women increased their scores as much as did women with more education. Nulliparous women also increased their posttest scores to comparable levels in women with previous deliveries. Women retested after delivery retained the educational message, achieving similar posttest and postdelivery scores (P=0.08).

CONCLUSION

Brief antenatal education increases mothers' understanding of basic newborn care. Mothers retain this knowledge into the early postpartum period and during early infancy when it might help reduce morbidity and mortality. The education was efficacious for women with little education. Brief antenatal educational modules seem a feasible, sustainable means of improving mothers' knowledge of newborn care. We speculate that similar programs could improve neonatal morbidity and mortality in developing countries.