Conference Material > Abstract
Josaphat A, Saldanha AM, Mwanga JP, Simon A
MSF Paediatric Days 2022. 2022 November 26; DOI:10.57740/ttb5-d359
INTRODUCTION
Tuberculosis (TB) and severe acute malnutrition (SAM) are major health problems in east Democratic Republic Congo (DRC), a setting with persistent armed conflict and population displacement. Diagnosis of TB in children is difficult as symptoms are non-specific and diagnostic sensitivity is low, especially in SAM.
CASE DESCRIPTION (Download PDF for photos accompanying this description)
A 4-year old girl was referred for a 2-week history of fever, cough, weight loss, and swelling of the limbs and face. On examination she was febrile and tachycardic, with pedal edema up to the knee, facial puffiness, and bilateral crepitations on auscultation. She lived in an overcrowded camp for internally displaced people. Her older brother had similar symptoms and neighbours had recently started TB treatment. She was admitted with a working diagnosis of SAM-Kwashiorkor type, acute pneumonia, and suspicion of TB. At day 5, her fevers continued despite IV broad-spectrum antibiotics. Chest x-ray was insignificant. Sputum microscopy and GeneXpert on gastric aspirate were both negative for TB. She developed abdominal distension and a spontaneous fistula at the umbilicus (photo), discharging milky fluid that was thought to be digested nutritional milk. Anti-tuberculosis treatment was started based on strong clinical suspicion of extra-pulmonary TB (EPTB). Within 2 weeks she improved clinically and nutritionally, the fistula spontaneously closed eliminating the need for surgery, and she could be discharged.
DISCUSSION
This case highlights the difficulties of diagnosing EPTB in children with SAM. Diagnosis relies heavily on clinical suspicion and epidemiological information. Negative sputum microscopy and GeneXpert gastric aspirate analysis do not rule out TB. Early initiation of treatment is the most important factor affecting mortality, thus empirically starting treatment should be considered. Spontaneous enterocutaneous fistulas caused by TB are rare, and there is limited literature describing their presentation or treatment. In our case, an empiric conservative treatment approach was very successful and even eliminated the need for surgery.
Tuberculosis (TB) and severe acute malnutrition (SAM) are major health problems in east Democratic Republic Congo (DRC), a setting with persistent armed conflict and population displacement. Diagnosis of TB in children is difficult as symptoms are non-specific and diagnostic sensitivity is low, especially in SAM.
CASE DESCRIPTION (Download PDF for photos accompanying this description)
A 4-year old girl was referred for a 2-week history of fever, cough, weight loss, and swelling of the limbs and face. On examination she was febrile and tachycardic, with pedal edema up to the knee, facial puffiness, and bilateral crepitations on auscultation. She lived in an overcrowded camp for internally displaced people. Her older brother had similar symptoms and neighbours had recently started TB treatment. She was admitted with a working diagnosis of SAM-Kwashiorkor type, acute pneumonia, and suspicion of TB. At day 5, her fevers continued despite IV broad-spectrum antibiotics. Chest x-ray was insignificant. Sputum microscopy and GeneXpert on gastric aspirate were both negative for TB. She developed abdominal distension and a spontaneous fistula at the umbilicus (photo), discharging milky fluid that was thought to be digested nutritional milk. Anti-tuberculosis treatment was started based on strong clinical suspicion of extra-pulmonary TB (EPTB). Within 2 weeks she improved clinically and nutritionally, the fistula spontaneously closed eliminating the need for surgery, and she could be discharged.
DISCUSSION
This case highlights the difficulties of diagnosing EPTB in children with SAM. Diagnosis relies heavily on clinical suspicion and epidemiological information. Negative sputum microscopy and GeneXpert gastric aspirate analysis do not rule out TB. Early initiation of treatment is the most important factor affecting mortality, thus empirically starting treatment should be considered. Spontaneous enterocutaneous fistulas caused by TB are rare, and there is limited literature describing their presentation or treatment. In our case, an empiric conservative treatment approach was very successful and even eliminated the need for surgery.
Journal Article > ResearchFull Text
Confl Health. 2022 May 7; Volume 16; 23.; DOI:10.1186/s13031-022-00440-6
Russell N, Tappis H, Mwanga JP, Black B, Thapa K, et al.
Confl Health. 2022 May 7; Volume 16; 23.; DOI:10.1186/s13031-022-00440-6
BACKGROUND
Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analyzing and learning lessons from such deaths in order to respond to and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle-income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA, and UNHCR on 17th–18th October 2019, informed by semi-structured interviews with a range of professionals, including experts attendees.
CONSULTATION FINDINGS
Interviewees revealed significant obstacles to the full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicization of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalization and implementation capacity for MPDSR within humanitarian organizations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to an improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings.
CONCLUSIONS
Despite the challenges, examples exist where the lessons learned from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.
Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analyzing and learning lessons from such deaths in order to respond to and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle-income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA, and UNHCR on 17th–18th October 2019, informed by semi-structured interviews with a range of professionals, including experts attendees.
CONSULTATION FINDINGS
Interviewees revealed significant obstacles to the full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicization of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalization and implementation capacity for MPDSR within humanitarian organizations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to an improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings.
CONCLUSIONS
Despite the challenges, examples exist where the lessons learned from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.
Conference Material > Slide Presentation
Josaphat A, Saldanha AM, Mwanga JP, Simon A
MSF Paediatric Days 2022. 2022 December 1; DOI:10.57740/17gw-fm44
Français
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2018 February 1; Volume 22 (Issue 2); 151-157.; DOI:10.5588/ijtld.17.0535
Nansumba M, Kumbakumba E, Orikiriza P, Bastard M, Mwanga JP, et al.
Int J Tuberc Lung Dis. 2018 February 1; Volume 22 (Issue 2); 151-157.; DOI:10.5588/ijtld.17.0535
BACKGROUND
In 2010, the World Health Organization (WHO) revised the paediatric dosages of anti-tuberculosis drugs, increasing rifampicin to 15 mg/kg, isoniazid to 10 mg/kg and pyrazinamide to 35 mg/kg. We assessed treatment outcomes, safety and adherence among children treated with the new recommended dosages.
METHODS
Prospective cohort of children started on anti-tuberculosis treatment in Uganda with 12 months of follow-up, including alanine aminotransferase (ALT) monitoring. Treatment intake was observed.
RESULTS
Of 144 treated children, 81 were male (56.3%), 106 (73.6%) were aged <5 years, 30 (22%) had moderate to severe malnutrition and 48 (33.3%) had human immunodeficiency virus infection. Treatment outcomes were as follows: 117 (81.3%) successes, 3 (2.1%) failures, 4 (2.8%) lost to follow-up, 19 (13.2%) deaths and 1 (0.7%) transferred out. There was no relapse. Severe malnutrition (adjusted hazard ratio 8.76, 95% confidence interval [CI] 1.59–48.25) was the only predictor of death. Two serious adverse events were attributed to treatment: one case of increased ALT and one with peripheral neuropathy. Median ALT values at baseline and at weeks 2, 4 and 8 were respectively 24 (interquartile range [IQR] 16–39), 26 (IQR 18–38), 28 (IQR 21–40) and 27 (IQR 19–38) international units/l. Treatment adherence was above 85% on all visits.
CONCLUSION
We confirm the good tolerability of and adherence to the new treatment recommendations. The increased risk of fatal outcome among severely malnourished children requires attention.
In 2010, the World Health Organization (WHO) revised the paediatric dosages of anti-tuberculosis drugs, increasing rifampicin to 15 mg/kg, isoniazid to 10 mg/kg and pyrazinamide to 35 mg/kg. We assessed treatment outcomes, safety and adherence among children treated with the new recommended dosages.
METHODS
Prospective cohort of children started on anti-tuberculosis treatment in Uganda with 12 months of follow-up, including alanine aminotransferase (ALT) monitoring. Treatment intake was observed.
RESULTS
Of 144 treated children, 81 were male (56.3%), 106 (73.6%) were aged <5 years, 30 (22%) had moderate to severe malnutrition and 48 (33.3%) had human immunodeficiency virus infection. Treatment outcomes were as follows: 117 (81.3%) successes, 3 (2.1%) failures, 4 (2.8%) lost to follow-up, 19 (13.2%) deaths and 1 (0.7%) transferred out. There was no relapse. Severe malnutrition (adjusted hazard ratio 8.76, 95% confidence interval [CI] 1.59–48.25) was the only predictor of death. Two serious adverse events were attributed to treatment: one case of increased ALT and one with peripheral neuropathy. Median ALT values at baseline and at weeks 2, 4 and 8 were respectively 24 (interquartile range [IQR] 16–39), 26 (IQR 18–38), 28 (IQR 21–40) and 27 (IQR 19–38) international units/l. Treatment adherence was above 85% on all visits.
CONCLUSION
We confirm the good tolerability of and adherence to the new treatment recommendations. The increased risk of fatal outcome among severely malnourished children requires attention.
Journal Article > ResearchFull Text
Malar J. 2017 May 23; Volume 16 (Issue 1); 218.; DOI:10.1186/s12936-017-1869-x
Coldiron ME, Lasry E, Bouhenia M, Das D, Okui P, et al.
Malar J. 2017 May 23; Volume 16 (Issue 1); 218.; DOI:10.1186/s12936-017-1869-x
Northern Uganda hosts a large population of refugees from South Sudan, and malaria is one of the major health problems in the area. In 2015, intermittent preventive treatment for malaria (IPTc) was implemented in two refugee camps among children aged 6 months to 14 years. Three distributions of dihydroartemisinin-piperaquine (DP) were conducted at 8-week intervals. The first dose was directly administered at IPTc distribution sites and the second and third doses were given to caregivers to administer at home. A multi-faceted evaluation was implemented, including coverage surveys, malaria prevalence surveys, reinforced surveillance, and pharmacovigilance. Programme coverage exceeded 90% during all three distributions with a total of 40,611 participants. Compared to same period during the previous year (only available data), the incidence of malaria in the target populations was reduced (IRR 0.73, 95% CI 0.69-0.77 among children under 5 years old; IRR 0.70, 95% CI 0.67-0.72 among children aged 5-14 years). Among those not targeted for intervention, the incidence between the 2 years increased (IRR 1.49, 95% CI 1.42-1.56). Cross-sectional surveys showed a prevalence of parasitaemia (microscopy or PCR) of 12.9-16.4% (95% CI 12.6-19.3) during the intervention, with the highest prevalence among children aged 5-14 years, but with a large increase 8 weeks after the final distribution. A total of 57 adverse events were reported during the intervention period, including one severe adverse event (death from varicella). Adverse events were of mild to moderate severity, and were mainly dermatologic and gastrointestinal. This is the first documentation of an IPTc programme in a refugee camp. The positive impact of DP on the incidence of malaria, together with its favourable safety profile, should lead to further use of IPTc in similar settings. Expanding coverage groups and decreasing intervals between distributions might provide more benefit, but would need to be balanced with the operational implications of a broader, more frequent distribution schedule.
Journal Article > ResearchFull Text
PLOS One. 2020 January 15; Volume 15 (Issue 1); DOI:10.1371/journal.pone.0227773
Crumley I, Halton J, Greig J, Kahunga L, Mwanga JP, et al.
PLOS One. 2020 January 15; Volume 15 (Issue 1); DOI:10.1371/journal.pone.0227773
Introduction: High quality diagnostic imaging can provide increased diagnostic accuracy and help guide medical decision-making and management, however challenges for radiology in resource-limited settings are numerous. Diagnostic imaging and teleradiology have financial and logistical implications, so evidence of impact is crucial. We sought to test the hypothesis that the implementation of computed radiography with teleradiology consultation support will significantly change diagnoses and treatment plans in a resource limited setting.
Method: Paired before-after study to determine the therapeutic impact of an add-on diagnostic test. 'Preliminary Plan' and 'Final Plan' forms allowed direct comparison of diagnosis and treatment plans at initial consultation and following radiography and teleradiology. Consecutive consenting patients were included until the sample size (600) was reached. Changes in both diagnosis and treatment plan were analysed in the whole cohort, with sub-analyses of children aged <5 years, and cases of chest radiography.
Results: Final analysis included 536 cases. Diagnosis changed following radiography and teleradiology in 62% of cases, and treatment plans changed in 61%. In chest radiography cases, 70% of diagnoses and 62% of treatment plans changed, while in children <5 years 66% of diagnoses and 58% of treatment plans changed. Reduced final treatment plans were most common for exploratory surgery (72% decrease), surgical orthopaedic intervention (62% decrease), and TB treatment (52% decrease), allowing more conservative medical or surgical management in 61 cases. Increased final treatment plans were highest in the orthopaedic and interventional surgery and referral categories. Of 42 cases requiring interventional surgery in the final plan, 26 (62%) were identified only after radiography and teleradiology. 16 additional cases were indicated for orthopaedic surgery, 10 cases required patient transfer, and TB treatment was indicated in 45 cases. A change in the original prescription plan occurred in 41% of 536 cases, with one or more prescriptions stopped in 28% of all cases.
Conclusion: We found that computed radiography with teleradiology had significant clinical value in this resource-limited setting, with the potential to affect both patient outcomes and treatment costs through providing improved diagnostics and avoiding unnecessary treatments and medications.
Method: Paired before-after study to determine the therapeutic impact of an add-on diagnostic test. 'Preliminary Plan' and 'Final Plan' forms allowed direct comparison of diagnosis and treatment plans at initial consultation and following radiography and teleradiology. Consecutive consenting patients were included until the sample size (600) was reached. Changes in both diagnosis and treatment plan were analysed in the whole cohort, with sub-analyses of children aged <5 years, and cases of chest radiography.
Results: Final analysis included 536 cases. Diagnosis changed following radiography and teleradiology in 62% of cases, and treatment plans changed in 61%. In chest radiography cases, 70% of diagnoses and 62% of treatment plans changed, while in children <5 years 66% of diagnoses and 58% of treatment plans changed. Reduced final treatment plans were most common for exploratory surgery (72% decrease), surgical orthopaedic intervention (62% decrease), and TB treatment (52% decrease), allowing more conservative medical or surgical management in 61 cases. Increased final treatment plans were highest in the orthopaedic and interventional surgery and referral categories. Of 42 cases requiring interventional surgery in the final plan, 26 (62%) were identified only after radiography and teleradiology. 16 additional cases were indicated for orthopaedic surgery, 10 cases required patient transfer, and TB treatment was indicated in 45 cases. A change in the original prescription plan occurred in 41% of 536 cases, with one or more prescriptions stopped in 28% of all cases.
Conclusion: We found that computed radiography with teleradiology had significant clinical value in this resource-limited setting, with the potential to affect both patient outcomes and treatment costs through providing improved diagnostics and avoiding unnecessary treatments and medications.