BACKGROUND
International recommendations advise against the use of intravenous rehydration therapy in children with severe acute malnutrition because of the concern about fluid overload, but evidence to support this concern is lacking. Given the high mortality associated with the current recommendations, the adoption of intravenous rehydration strategies might improve outcomes.
METHODS
We conducted a factorial, open-label superiority trial in four countries in Africa. Children 6 months to 12 years of age with severe acute malnutrition with gastroenteritis and dehydration underwent randomization in a 2:1:1 ratio to one of three rehydration strategies: oral rehydration, plus intravenous boluses for shock; a rapid intravenous strategy that consisted of lactated Ringer’s solution (100 ml per kilogram of body weight) administered over a period of 3 to 6 hours, with boluses for shock; or a slow intravenous strategy that consisted of the same solution administered over a period of 8 hours, with no boluses. The primary end point was death at 96 hours.
RESULTS
A total of 272 children underwent randomization; 138 were assigned to the oral strategy, 67 to the rapid intravenous strategy, and 67 to the slow intravenous strategy. Participants were followed for 28 days. A nasogastric tube was used for oral rehydration in 126 of 135 participants (93%) in the oral group and in 82 of 126 (65%) in the intravenous groups. Intravenous boluses were administered at admission in 12 participants (9%) in the oral group, 7 (10%) in the rapid intravenous group, and none in the slow intravenous group. At 96 hours, 11 participants (8%) in the oral group and 9 (7%) in the intravenous groups (5 in the rapid group and 4 in the slow group) had died (risk ratio, 1.02; 95% confidence interval [CI], 0.41 to 2.52; P=0.69). At 28 days, 17 participants (12%) in the oral group and 14 (10%) in the intravenous groups had died (hazard ratio, 0.85; 95% CI, 0.41 to 1.78). Serious adverse events occurred in 32 participants (23%) in the oral group, 14 (21%) in the rapid intravenous group, and 10 (15%) in the slow intravenous group. No evidence of pulmonary edema, heart failure, or fluid overload was noted.
CONCLUSIONS
Among children with severe acute malnutrition and gastroenteritis, no evidence of a difference in mortality at 96 hours was noted between oral and intravenous rehydration strategies. (Funded by the Joint Global Health Trials scheme and others; GASTROSAM Current Controlled Trials number, ISRCTN76149273.)
BACKGROUND
Since August 2017, approximately 960,000 Rohingya refugees have settled in Cox’s Bazar, Bangladesh. Water, sanitation, and hygiene (WASH) infrastructure and programs were implemented across the camps to address the needs of the population and reduce the burden of linked infectious diseases. However, monitoring and maintenance of this infrastructure has been inconsistent. This study aimed to assess progress in WASH in the camps of Cox’s Bazar since the early emergency phase in 2018, and to update the priorities for intervention.
METHODS
From January to March 2022, a lot quality assurance sampling (LQAS) survey was conducted across 19 camps. Nineteen households were randomly selected per camp. Data on access to and quality of WASH services, household practices, and health outcomes including skin infections among children under five years of age were collected. Crude and weighted averages with 95% confidence intervals were calculated for each indicator and compared with targets pre-defined based on Sphere guidelines and Médecins Sans Frontières WASH experts. Chi-squared tests were used to compare the results to a 2018 LQAS survey.
RESULTS
More than half of the indicators (59%; 16/27) did not meet the pre-determined targets. Performance was adequate on three of five water quality and supply indicators, with less than half of households (44%, 95% CI: 39–49%) reporting that water was continuously available in the past week. Regarding water storage, performance on three indicators was considered adequate, as the proportion of households that keep water for less than one day was 27% (95% CI: 23-32%). Of six hygiene indicators, adequate performance was identified for only one. Performance on the sanitation indicators was inadequate, with 11% (95% CI: 8-15%) of households using an improved sanitation facility. In solid waste management, two of four indicators suggested adequate performance, and for health outcomes, the proportion of children who hadn’t shown any skin infection was inadequate at 69% (95% CI: 64-73%).
CONCLUSIONS
Improvements in the WASH situation in Cox’s Bazar have been observed in 2022 compared to 2018. However, significant gaps remain in water supply, sanitation facilities, and hygiene services. LQAS can be an effective monitoring tool to support long-term multisectoral interventions in protracted emergencies.
This case report presents a rare instance of concomitant splenic tuberculosis (TB), Epstein–Barr virus (EBV)-related T-cell leukemia/lymphoma, and malaria in a 28-year-old pregnant woman at a Médecins Sans Frontières-supported hospital in South Sudan. The patient was admitted with splenomegaly, anorexia, weakness, and transfusion-refractory anemia. She tested positive for malaria and was treated appropriately. Because of ongoing consumptive anemia, cachexia, and weakness severely impacting her quality of life, the patient underwent splenectomy. A diagnosis of TB was ultimately confirmed post-splenectomy through histopathological analysis and molecular testing. Gross findings from the pathologic analysis of a splenic sample revealed miliary deposits, necrotizing granulomas, and atypical lymphocytic infiltrates consistent with TB and EBV-associated leukemia/lymphoma. Despite temporary improvement post-operatively and the initiation of TB therapy, the patient discontinued treatment and was lost to follow-up, likely resulting in mortality. This report presents an unusual combination of concomitant pathologies that underscore the diagnostic challenges and complexity of managing overlapping infectious and hematological disorders in resource-limited settings.
INTRODUCTION
This clinical practice guideline from the Explosive Weapons Trauma Care Collective (EXTRACCT) group provides a review of current best practice for the management of urogenital injury after blast injury due to unexploded ordinance and improvized explosive devices. In particular, landmine‐related blasts are a continuing problem and this plagues lower‐income and middle‐income regions disproportionately.
METHODS
An expert literature review of current practice is presented.
RESULTS
The guideline provides assessment, resuscitation, and definitive management based on injury severity for the internal urological organs and for the external genitalia. Imaging and surgical techniques are described for the surgeon relatively unfamiliar with the management of urogenital trauma.
CONCLUSION
Urogenital trauma is seldom fatal but combined with other injuries may cause severe morbidity and mortality. Best practice management is required in resource‐constrained settings.
BACKGROUND
COVID-19 hit Canada hard and exacerbated health inequities, notably among ethnoracially minoritized populations. By August 2021, some areas in Peel region (Ontario, Canada) continued to have high COVID-19 infection rates and low COVID-19 vaccine coverage. To increase first dose uptake, Peel Public Health implemented smaller community-based vaccination clinics in addition to pre-existing mass vaccination (fixed) clinics. This study describes these community clinics and those who received their first dose at a community clinic to determine whether local public health efforts to implement community clinics reached different population groups and whether these community clinics contributed to an increase in uptake of the first dose of COVID-19 vaccines.\
METHODS
We conducted a descriptive, cross-sectional study using data from the Ontario COVID-19 vaccination registry (COVaxON). We included eligible Peel residents 12 years and older who received a COVID-19 vaccine within community and fixed clinics between September 2021 and August 2022. Clinics were classified based on clinic type (community/fixed), and location. COVID-19 vaccine uptake for smaller geographic areas designated by postal codes was calculated at the beginning and end of the study period. Clinic and attendee characteristics were analyzed using descriptive statistics.
RESULTS
There were 177 community and 11 fixed clinic sites that operated during the study period. Community clinics administered 98,965 doses (27%) of COVID-19 vaccine and fixed clinics administered 264,021 doses (73%). A slightly higher proportion of first doses were administered in community clinics (8.1%) compared to fixed clinics (7.9%) and community clinics saw a higher proportion of first dose recipients from low-coverage areas (23% versus 19% in fixed clinics). Clinics in faith-based organizations, schools and shopping areas administered the most doses among community clinic locations. The absolute increase in first dose vaccine uptake was 11% over the study period.
CONCLUSIONS
Almost 100,000 doses of COVID-19 vaccine were administered in community clinics, which contributed to increased overall vaccine coverage in Peel region. A slightly higher proportion of first doses were administered in community clinics compared to fixed clinics and a higher proportion of doses to residents of low-coverage areas.
The World Health Organization has called for operational research on all-oral shorter regimens for rifampin-resistant and multidrug-resistant forms of tuberculosis (RR/MDR-TB). We followed a cohort of patients in Zhytomyr, Ukraine for effectiveness, safety, tolerability and feasibility of bedaquiline & delamanid-based treatment regimens under programmatic conditions. This was a single-arm implementation study. All consenting persons with RR/MDR-TB were enrolled between 1 April 2019 and 31 May 2021 and followed up 12-months after treatment completion. We assessed quality of life and depression symptoms between start and end-of-treatment. We enrolled 300 patients. Overall, 212 (71%) patients were cured, 22 (7%) patients completed treatment, median time to culture conversion was 58 days (IQR:30–75), and 21% and 27% of patients had at least one serious or Grade 3/4 adverse event, respectively. The overall BREF-WHO/Quality of Life score improved between baseline and end-of-treatment, from average 52.64(std. dev:21.63) to 57.15(std. dev:21.43) while Patient Health Questionnaire-9(PHQ-9) score decreased from 6.67(std. dev:4.75) at baseline to 5.34(std. dev: 5.18) at end-of-treatment. Twelve months post-treatment 174/234(74%) were alive and recurrence-free, 17(7%) patients died, one (<1%) had recurrent TB, while 42 (18%) were lost from the post-treatment follow-up. All-oral short-term regimens showed high success under programmatic conditions in Ukraine, despite extreme implementation challenges during the COVID-pandemic and the Russia-Ukraine war. Moreover, this was a cohort of patients with high levels of co-morbidities and substance use. A multidisciplinary, psychosocial support model might have contributed to satisfactory treatment outcomes, improved quality of life and decreased symptoms of depression among people living with RR/MDR-TB.
BACKGROUND
The management of post-meningitis sequelae is a priority in the WHO Roadmap to Defeat Meningitis by 2030. Nonetheless, the prevalence of sequelae in the African Meningitis Belt is not well described, making the development of post-meningitis care programmes difficult. We conducted a home-based follow-up study of cases notified during an epidemic due to Neisseria meningitidis serogroup C (NmC) in 2022 in the Dungass and Magaria Districts of Niger, to describe the prevalence of sequelae several months after the epidemic.
METHODS
Standard WHO case definitions were used during the epidemic. District linelists were completed with the results of PCR testing of patients who had undergone lumbar puncture. These lists included the village of origin of the notified cases. Accompanied by community outreach workers, the study’s nurse-investigators sought out case-patients in their homes to assess the presence of sequelae. A standardised questionnaire was administered, and a focused physical examination was carried out.
RESULTS
A total of 1001 suspected cases and 50 deaths (CFR 5.0%) were reported in the two districts. A total of 469 CSF samples (47%) were analysed at the national reference laboratory, of which 220 were PCR positive (47%). NmC was the predominant causative organism (87% of confirmed cases). 82 cases were excluded due to distance. 570 of the 919 cases sought out were eventually found and included. Of these 570 cases, 49 had died (CFR 8.6%). Among surviving cases, the prevalence of sequelae was 12%, and among survivors of confirmed NmC meningitis, 18%. The most common sequelae were hearing loss (6%), paralysis (3%) and epilepsy (2%).
DISCUSSION
Case fatality during the epidemic appears to have been higher than reported in routine surveillance. The prevalence of severe sequelae is high, and clinical description of sequelae could help future epidemic management.
BACKGROUND
The mental health problems during the coronavirus disease 2019 (COVID-19) pandemic may have influenced their decision to receive the COVID-19 vaccine among health-related university students, with potential differences across countries. This study elucidated the association between mental health and COVID-19 vaccine hesitancy of health-related university students in Thailand, Laos, and Japan. We additionally examined the other factors that might relate to COVID-19 vaccine hesitancy.
METHODS
The study conducted an online survey from February 4 to 27, 2021, among undergraduate students enrolled in health-related programs at University of Health Sciences (Lao PDR), Walailak University (Thailand), and Nagasaki University (Japan) using a non-probability convenience sampling method. The data were analyzed using multiple logistic regression to identify associations between mental health and self-reported COVID-19 vaccine hesitancy and other potential factors.
RESULTS
This study analyzed data from 841 students. Japanese students attended hybrid classes (82.45%), while those in Laos and Thailand had entirely online courses. All mental health assessment scores (depression, anxiety, and stress) were higher in Thailand and Laos compared to Japan. Students with very high-stress scores had the highest odds of vaccine hesitancy (aOR 2.67, 95% CI 1.45–4.93). Fear of COVID-19 increased hesitancy, while unbelief in vaccine protection significantly increased it (aOR 2.59, 95% CI 1.86–3.59). Females displayed about two times greater hesitancy (adjusted odds ratio, aOR 2.43, 95% CI 1.68–3.51), which correlated with higher mental health scores.
CONCLUSIONS
We highlighted a significant association between mental health and self-report COVID-19 vaccine hesitancy. Interventions, including tailored support, awareness campaigns, and psychological services, can foster trust and vaccine uptake.
This case series discusses three instances of telefono-type physical violence collected during a Médecins Sans Frontières (MSF) mission rescuing migrants crossing the Mediterranean from Libya. These cases demonstrate the various sequelae of ear-cuffing, including subjective hearing loss, tinnitus, ear pain, tympanic membrane rupture, and infection in this under-studied type of physical violence. The authors hope this case series further demonstrates the importance of awareness and recognition of subtle presentations of different types of torture.