Lower respiratory tract infection admissions and deaths among children under 5 years in public sector facilities in the Western Cape Province, South Africa, before and during the COVID-19 pandemic (2019 - 2021).

BACKGROUND: The COVID-19 pandemic resulted in the implementation of strict public health and social measures (PHSMs) (including mobility restrictions, social distancing, mask-wearing and hand hygiene), limitations on non-essential healthcare services, and public fear of COVID-19 infection, all of which potentially affected transmission and healthcare use for other diseases such as lower respiratory tract infections (LRTIs). OBJECTIVE: To determine changes in LRTI hospital admissions and in-facility mortality in children aged <5 years in the Western Cape Province during the pandemic. METHODS: We conducted a retrospective analysis of LRTI admissions and in-facility deaths from January 2019 to November 2021. We estimated changes in rates and trends of LRTI admissions during the pandemic compared with pre-pandemic period using interrupted time series analysis, adjusting for key characteristics. RESULTS: There were 36 277 children admitted for LRTIs during the study period, of whom 58% were male and 51% were aged 28 days - 1 year. COVID-19 restrictions were associated with a 13% step reduction in LRTI admissions compared with the pre-COVID-19 period (incidence rate ratio (IRR) 0.87, 95% confidence interval (CI)) 0.80 - 0.94). The average LRTI admission trend increased on average by 2% per month during the pandemic (IRR 1.02, 95% CI 1.02 - 1.04). CONCLUSIONS: The COVID-19 surges and their associated measures were linked to declining LRTI admissions and in-facility deaths, likely driven by a combination of reduced infectious disease transmission and reduced use of healthcare services, with effects diminishing over time. These findings may inform future pandemic response policies.

Examining the reliability of ICD-10 discharge coding in Red Cross War Memorial Children's Hospital administrative database.

BACKGROUND: Discharge diagnostic data from hospital administrative databases are often used to inform decisions relating to a variety of vital applications. These may include the allocation of resources, quality-of-care assessments, clinical research and formulation of healthcare policy. Accurately coded and reliably captured patient discharge data are of paramount importance for any hospital and health system to function efficiently. OBJECTIVES: To retrospectively examine the reliability of the International Classification of Diseases version 10 (ICD-10) discharge coding in Red Cross War Memorial Children's Hospital (RCWMCH)'s administrative database for primary and secondary discharge diagnoses, and to formulate recommendations for improvement to the current system. METHODS: This study was a retrospective folder review of 450 patient admissions to the short-stay and general paediatric wards at RCWMCH between 1 August 2013 and 1 September 2014. The principal investigator (PI) completed ICD-10 discharge coding for each admission and compared it with the corresponding admission data captured for each patient in the Clinicom (Siemens Medical Solutions, Germany) health information system. Agreement comparison was done to 4- and 3-character ICD-10 code specificity. RESULTS: Of the initial 450 randomly selected folders, 396 (88%) were analysed during the folder review process. The median number of total diagnoses (primary diagnosis plus secondary diagnoses) coded by the PI folder review was 3, with a distribution of 1 - 10 (interquartile range (IQR) 2 - 4). The median number of total diagnoses coded in Clinicom was 1, with a distribution of 1 - 3 (IQR 1 - 1). Agreement of primary diagnosis coding to 4 characters was 26.3%, with slight improvement to 34.3% when assessed to 3 characters. Agreement of secondary diagnoses to 4 characters was 14.9%, and 27.7% when assessed to 3 characters. CONCLUSIONS: Reliability of administrative ICD-10 discharge data from RCWMCH is poor. Inadequacies regarding the employment of dedicated and/or adequately trained coding personnel may significantly contribute to the problem and should be addressed.

The African Hospitalist Fellowship.

The African Paediatric Fellowship Programme is rolling out a training course for newly qualified paediatricians to equip them with the leadership skills to function in complex general paediatric settings. The care of children in Africa carries its own unique demands, from the layering effects of multiple conditions through to establishing and sustaining services under severe resource constraints. This novel training concept aims to strengthen confidence and knowledge in areas that are not priorities during standard general paediatric training. The skills gained are considered of great relevance in assisting general paediatricians to achieve their full potential in their careers.

A review of blood transfusions in a trauma unit for young children.

BACKGROUND: Trauma is the leading cause of mortality and morbidity worldwide. Blood transfusions play an incremental role in the acute phase, yet practice varies owing to variations in transfusion thresholds and concerns about potential complications, especially in children. OBJECTIVES: To evaluate protocol adherence to blood transfusion thresholds in paediatric trauma patients and determine the degree of blood product wastage, as defined by discarded units. METHODS: A retrospective, descriptive study of trauma patients (age 0 - 13 years) who received a blood transfusion in the trauma unit at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, over a 5.5-year period (1 January 2009 - 1 July 2014). Haemoglobin (Hb) transfusion thresholds were defined as 10 g/dL for neurotrauma patients and patients requiring skin grafting or a musculocutaneous flap (group 1). All other trauma patients had an Hb transfusion threshold of 7 g/dL (group 2). RESULTS: A total of 144 patients were included (mean age 5.2 years (standard deviation (SD) 3.3), 68.1% male). The mean Hb increase after transfusion was 3.5 g/dL (SD 1.7). Adherence to the transfusion Hb threshold protocol was 96.7% for group 1 v. 34.0% for group 2. No complications were reported. Average blood wastage was 3.5 units per year during the study period. CONCLUSIONS: Adherence to paediatric blood transfusion protocol was low in the Hb threshold group <7 g/dL. However, transfusion-related complications and wastage were minimal. Further prospective research is required to determine optimal blood transfusion guidelines for paediatric trauma patients.

Risk factors for unsuccessful lumbar puncture in children.

BACKGROUND: This descriptive study provides the first information on an association between the use of sedation and a reduction in the prevalence of unsuccessful lumbar puncture (LP) in African children of all races. OBJECTIVE: Our hypothesis was that children who do not receive any procedural sedation are more likely to have unsuccessful LPs. METHODS: A cross-sectional observational study examined LPs performed from February to April 2013, including details of the procedure, sedation or analgesia used, and techniques. The setting was the Medical Emergency Unit at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, and the participants all children aged 0 - 13 years who had an LP in the unit during the time period. RESULTS: Of 350 children, 62.9% were <12 months of age, the median age being 4.8 months (interquartile range 1.5 - 21.7). The prevalence of unsuccessful (traumatic or dry) LP was 32.3% (113/350). Sedation was used in 107 children (30.6%) and was associated with a reduction in the likelihood of unsuccessful LP (p=0.002; risk ratio (RR) 0.5 (95% confidence interval (CI) 0.34 - 0.78)) except in those <3 months of age, where sedation did not significantly reduce the likelihood (p=0.56; RR 1.20 (95% CI 0.66 - 2.18)). CONCLUSIONS: Unsuccessful LP was common. Sedation was not routinely used, but the results suggest that it may be associated with a reduction in the rate of unsuccessful LP. Unsuccessful LP may lead to diagnostic uncertainty, prolonged hospitalisation and unnecessary antibiotic use. Whether a procedural sedation protocol would reduce the rate of unsuccessful LP requires further study.

Vital signs for children at triage: a multicentre validation of the revised South African Triage Scale (SATS) for children.

OBJECTIVE: To validate a revised version of the paediatric South African Triage Scale (SATS) against admission as a reference standard and compare the sensitivity of triage using: (i) clinical discriminators; (ii) an age-appropriate physiological composite score; and (iii) a combination of both. METHODS: A prospective cohort study was undertaken validating the revised paediatric SATS against outcome markers of children at six emergency centres during a 2-month period in 2011. The primary outcome marker was the proportion of children admitted. Validity indicators including sensitivity (Se), specificity, positive predictive value and negative predictive value (NPV) were used to estimate the validity. Associated percentages for over-/under-triage were used to further assess practical application of the paediatric SATS. RESULTS: A total of 2 014 children were included. The percentage of hospital admissions increased with an increase in the level of urgency from 5% in the non-urgent patients to 73% in the emergency patients. The data demonstrated that sensitivity increased substantially when using the SATS, which is a combination of clinical discriminators and the Triage Early Warning Score (TEWS) (Se 91.0%, NPV 95.3%), compared with use of clinical discriminators in isolation (Se 57.1%, NPV 86.3%) or the TEWS in isolation (Se 75.6%, NPV 89.1%). CONCLUSION: The results of this study illustrate that the revised paediatric SATS is a safe and robust triage tool.

An adapted triage tool (ETAT) at Red Cross War Memorial Children's Hospital Medical Emergency Unit, Cape Town: an evaluation.

OBJECTIVE: To evaluate the efficacy of an adapted Emergency Triage Assessment and Treatment (ETAT) tool at a children's hospital. DESIGN: A two-armed descriptive study. SETTING: Red Cross War Memorial Children's Hospital, Cape Town, South Africa. METHODS: Triage data on 1 309 children from October 2007 and July 2009 were analysed. The number of children in each triage category (red (emergency), orange (urgent or priority) and green (non-urgent)) and their disposal were evaluated. RESULTS: 1. The October 2007 series: 902 children aged 5 days - 15 years were evaluated. Their median age was 20 (interquartile range (IQR) 7 - 50) months, and 58.8% (n=530) were triaged green, 37.5% (n=338) orange and 3.8% (n=34) red. Over 90% of children in the green category were discharged (478/530), while 32.5% of children triaged orange (110/338) and 52.9% of children triaged red (18/34) were admitted. There was a significant increase in admission rate for each triage colour change from green through orange to red after adjustment for age category (risk ratio (RR) 2.6; 95% confidence interval (CI) 2.2 - 3.1). 2. The July 2009 cohort: 407 children with a median age of 22 months (IQR 7 - 53 months) were enrolled. Twelve children (2.9%) were triaged red, 187 (45.9%) orange and 208 (51.1%) green. A quarter (101/407) of the children triaged were admitted: 91.7% (11/12) from the red category and 36.9% (69/187) from the orange category were admitted, while 89.9% of children in the green category (187/208) were discharged. After adjusting for age category, admissions increased by more than 300% for every change in triage acuity (RR 3.2; 95% CI 2.5 - 4.1). CONCLUSIONS: The adapted ETAT process may serve as a reliable triage tool for busy paediatric medical emergency units in resource-constrained countries and could be evaluated further in community emergency settings.

The role of nutrition and micronutrients in paediatric HIV infection.

It has been postulated that micronutrients play a role in the pathogenesis of HIV disease. Though data are sparse, there is evidence that HIV-infected adults and children have a range of micronutrient deficiencies with increasing severity in advanced disease and in the presence of malnutrition. It appears that micronutrient deficiencies contribute to immune dysfunction, infectious morbidity and disease progression. Limited interventive studies suggest that vitamin and mineral supplementation is beneficial to HIV-infected adults and children; however, current, regimens are not evidence-based and there are no randomised controlled trials in children. There are a number of African studies under way addressing these issues.

Disseminated strongyloidiasis in a child with lymphoblastic lymphoma.

PURPOSE: This report describes a case of disseminated strongyloidiasis in a child receiving chemotherapy for T-cell lymphoblastic lymphoma. PATIENT AND METHODS: A 10-year-old boy became severely ill with disseminated strongyloidiasis 4 weeks after starting chemotherapy for T-cell lymphoblastic lymphoma. He responded to treatment with supportive care, antibiotics, and albendazole but required ivermectin to eradicate the strongyloides infection. CONCLUSION: Disseminated strongyloidiasis is a severe, life-threatening complication of Strongyloides stercoralis infection that can occur in patients on immunosuppressive therapy, particularly when this therapy includes corticosteriods. In endemic areas, screening patients due to undergo immunosuppressive treatment and appropriate antistrongyloides treatment may be life saving. Ivermectin is the treatment of choice.

A specific and sensitive PCR assay suitable for large-scale detection of toxigenic Pasteurella multocida in nasal and tonsillar swabs specimens of pigs.

A polymerase chain reaction (PCR) assay for the detection of toxigenic Pasteurella multocida in nasal and tonsillar swab specimens collected from pigs was developed. Target DNA was isolated with guanidine thiocyanate and diatomite, and 2 primer sets derived from sequences in the gene that encodes the dermonecrotic toxin of P. multocida were used simultaneously. The method was adapted to microtiter plate format allowing large-scale use of the PCR assay. To identify false-negative test results caused by failure of amplification, a positive control template was constructed that was spiked to each DNA sample. The PCR assay was evaluated with clinical samples and compared with 2 routinely used methods for detection of toxigenic P. multocida: isolation from a selective agar and direct detection of the toxin in extracts of primary cultures by an enzyme-linked immunosorbent assay (ELISA). The sensitivity of the PCR assay was tested with 346 nasal and tonsillar swabs specimens collected from pigs of 9 herds known to be infected with toxigenic P. multocida. Toxigenic P. multocida was isolated from 22 specimens, only 28 specimens tested positive in ELISA, but 40 tested positive in the PCR assay; thus the PCR assay is the most sensitive of the 3 methods. The specificity of the PCR assay was tested with 372 swab specimens collected from pigs of 6 herds certificated to be free from toxigenic P. multocida. Toxigenic P. multocida was not isolated from any of these specimens, all tested negative in ELISA, and 370 tested negative in PCR. The 2 positive specimens came from 2 pigs of 1 litter and tested only weakly positive in the PCR assay. From these results, it was concluded that the PCR assay is not only highly sensitive but also highly specific.

Suprapubic aspiration under ultrasound guidance in children with fever of undiagnosed cause.

OBJECTIVES: To assess the ease of use of suprapubic aspiration of urine under ultrasound guidance in babies with fever of uncertain cause and to assess the importance of bacterial counts and pyuria in relation to abnormalities of the urinary tract and the importance of pyuria in the absence of bacteriuria. DESIGN: Analysis of urine samples obtained by suprapubic aspiration in babies and children from July 1991 to June 1992. The clinical records of the children with bacteriuria and sterile pyuria were examined retrospectively. SETTING: Neonatal and paediatric wards of a district general hospital. SUBJECTS: 508 babies and children who had fever of uncertain cause or were seriously ill. RESULTS: No difficulties arose in the collection of 545 specimens. Bacteria were isolated from the specimens of 44 children, 24 of whom had abnormalities of the urinary tract. The bacterial count was < 10(8)/l in 18 of the children with bacteriuria, 10 of whom had abnormalities. No white cells were seen in 22 of the 46 bacteriuric specimens; nine of the children with no pyuria had vesicoureteric reflux. 439 of the 499 non-bacteriuric specimens showed no white cells. 60 children had pyuria without bacteriuria. CONCLUSIONS: The use of ultrasound guidance simplifies suprapubic aspiration of urine in babies. Low bacterial counts may be associated with abnormalities of the urinary tract. Laboratory techniques capable of detecting such counts reliably should be used. Pyuria is absent in half of babies and very young children with bacteriuria. It rarely occurs without bacteriuria, and if it does an explanation should be sought.