Non-Malaria Causes of Fever among under-5 Children with Negative Results for Malaria Rapid Diagnostic Test in South-Western Nigeria.

BACKGROUND: Although the global malaria burden is decreasing, there are still concerns about overdiagnosis of malaria and the danger of misdiagnosis of non-malaria causes of fever. Clinicians continue to face the challenge of differentiating between these causes despite the introduction of malaria rapid diagnostic tests (mRDTs). AIM: To determine the prevalence and causes of non-malaria-caused fever in children in South-Western Nigeria. METHODS: Secondary analysis of data obtained to evaluate the effect of restricting antimalarial treatment to positive mRDT children in rural and urban areas of southwest Nigeria. Clinical examinations, laboratory tests for malaria parasites (including thick blood film and mRDT) and bacterial identification were performed on children aged 3-59 months (n = 511). The non-malaria group comprised febrile children who had both negative mRDT and microscopy results, while the malaria group included those who were positive for either mRDT or microscopy. We compared the causes of fever among children with non-malaria fever and those with malaria. RESULTS: The prevalence of non-malaria fever and bacteria-malaria co-infection was 37.2% and 2.0%, respectively. Non-malarial pathogens identified were viral (54.7%) and bacterial (32.1%) infections. The bacterial infections included bacteriaemia (2.7%), urinary tract infections (21.6%), skin infections (11.6%) and otitis media (2.6%). The leading bacterial isolates were Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pneumoniae. CONCLUSION: The high prevalence and wide range of non-malarial infections reinforces the need for point-of-care tests to identify bacterial and viral infections to optimize the treatment of febrile illnesses in malaria-endemic areas.

Paediatric end-stage renal disease in a tertiary hospital in South West Nigeria.

BACKGROUND: Children and adolescents with end-stage renal disease (ESRD) in sub-Saharan Africa may have the worst outcomes globally. Barriers to management include late presentation, poor socioeconomic conditions, absence of medical insurance, limited diagnostic facilities and non-availability of chronic renal replacement therapy (RRT). Our study was to determine the incidence, aetiology, management and outcomes of paediatric ESRD in a tertiary hospital in Nigeria. METHODS: A retrospective case review of paediatric ESRD at the University College Hospital Ibadan, Nigeria, over 8 years, from January 2005 to December 2012. RESULTS: 53 patients (56.6% male), median age 11 (inter quartile range 8.5-12) years were studied. Mean annual incidence of ESRD in Ibadan for children aged 14 years and below was 4 per million age related population (PMARP) while for those aged 5-14 years it was 6.0 PMARP. Glomerulonephritis was the cause in 41 (77.4%) patients amongst whom, 29 had chronic glomerulonephritis and 12 had nephrotic syndrome. Congenital anomalies of the kidneys and urinary tract (CAKUT) accounted for 11 (21.2%) cases, posterior urethral valves being the most common. Acute haemodialysis, acute peritoneal dialysis or a combination of these were performed in 33 (62.3%), 6 (11.3%) and 4 (7.5%) patients respectively. Median survival was 47 days and in-hospital mortality was 59%. CONCLUSIONS: Incidence of paediatric ESRD in Ibadan is higher than previous reports from sub-Saharan Africa. Glomerulonephritis, and then CAKUT are the most common causes. Mortality is high, primarily due to lack of resources. Preventive nephrology and chronic RRT programmes are urgently needed.

SD-Bioline malaria rapid diagnostic test performance and time to become negative after treatment of malaria infection in Southwest Nigerian Children.

Context and Aim: Given the challenges of microscopy, we compared its performance with SD-Bioline malaria rapid diagnostic test (MRDT) and polymerase chain reaction (PCR) and evaluated the time it took for positive results to become negative after treatment of children with acute uncomplicated malaria. Subjects and Methods: We present the report of 485 participants with complete MRDT, microscopy, and PCR data out of 511 febrile children aged 3-59 months who participated in a cohort study over a 12-month period in rural and urban areas of Ibadan, Nigeria. MRDT-positive children received antimalaria and tested at every visit over 28 days. Speciation was also carried out by PCR. Results: With microscopy as the gold standard, SD-Bioline™ had 95.2% sensitivity, 66.4% specificity, 67.5% positive predictive value (PPV), and 94.9 negative predictive value (NPV), while with PCR the findings were 84.3% sensitivity, 66.5% specificity, 72.7% PPV, and 80.1% NPV. PCR speciation of malaria parasites revealed 91.6% Plasmodium falciparum, 18.9% Plasmodium malariae, and 4.4% Plasmodium ovale. Among the 47 children with P. malariae infections, 66.0% were coinfected with P. falciparum, while 54.6% cases of P. ovale occurred as coinfections with P. falciparum. The median time to a negative MRDT was 23.2 days, while the median time to a negative malaria microscopy was 3.8 days. The two survival curves were significantly different. Conclusions: The SD-BiolineTM MRDT performed well, with remarkable persistence of rapid test-positive for an average of 23 days post treatment. The prevalence of P. malaria is somewhat greater than expected.

Résumé Contexte et objectif: Compte tenu des défis de la microscopie, nous avons comparé le test de diagnostic rapide du paludisme SD-Bioline (MRDT) avec la réaction en chaîne par polymérase (PCR) et évalué le temps qu'il a fallu pour que des résultats positifs deviennent négatifs après le traitement d'enfants atteints de paludisme aigu non compliqué. Sujets et méthodes: Nous présentons le rapport de 485 participants avec des données complètes de MRDT, de microscopie et de PCR sur 511 enfants fébriles âgés de 3 à 59 mois qui ont participé à une étude de cohorte sur une période de 12 mois dans les zones rurales et urbaines d'Ibadan, Nigeria. Les enfants positifs au MRDT ont reçu un antipaludique et ont été testés à chaque visite pendant 28 jours. La spéciation a également été réalisée par PCR. Résultats: Avec la microscopie comme référence, SD-Bioline TM avait une sensibilité de 95,2 %, une spécificité de 66,4 %, une valeur prédictive positive (VPP) de 67,5 % et une valeur prédictive négative (VPN) de 94,9 %, tandis qu'avec la PCR, les résultats étaient de 84,3 % de sensibilité, 66,5 % de spécificité, 72,7 % de VPP et 80,1 % de VPN. La spéciation par PCR des parasites du paludisme a révélé 91,6 % de Plasmodium falciparum, 18,9 % de Plasmodium malariae et 4,4 % de Plasmodium ovale. Parmi les 47 enfants atteints d'infections à P. malariae, 66,0 % étaient co-infectés par P. falciparum, tandis que 54,6 % des cas de P. ovale se sont produits sous forme de co-infections par P. falciparum. Le délai médian jusqu'à un MRDT négatif était de 23,2 jours, tandis que le délai médian jusqu'à une microscopie négative du paludisme était de 3,8 jours. Les deux courbes de survie étaient significativement différentes. Conclusions: Le SD-BiolineTM MRDT a donné de bons résultats, avec une infection à P. malariae un peu plus élevée que attendu dans la population et persistance remarquable des résultats positifs aux tests de diagnostic rapide pendant une moyenne de plus de 23. Mots-clés: Paludisme, microscopie, Nigéria, réaction en chaîne par polymérase, test de diagnostic rapide, spéciationjours après le traitement.

Evaluation of the efficacy and safety of artemether-lumefantrine in the treatment of acute uncomplicated Plasmodium falciparum malaria in Nigerian infants and children.

BACKGROUND: The six-dose regimen of artemether-lumefantrine (AL) is now considered the gold standard for the treatment of uncomplicated Plasmodium falciparum malaria. There are few reports evaluating co-artemether in very young Nigerian infants and children. Results of the evaluation of the six-dose regimen in very young infants and children in Nigeria are presented in this report. METHODS: As part of a larger African study, this open label, non-comparative trial, assessed the efficacy and safety of six-dose regimen of AL tablets in 103 Nigerian infants and children weighing between five and 25 kg suffering from acute uncomplicated malaria. Treatment was administered under supervision over three days with children as in-patients. 12-lead ECG tracings were taken pre-treatment and at day 3. RESULTS: Ninety-three infants and children completed the study as stipulated by the protocol. Mean fever and parasite clearance times for the intent to treat population (ITT) were 24.9 h +/- (1.28) and 26 h +/- (4.14) and the corresponding figures for the per-protocol population (PP) were 19.24 h +/- 13.9 and 25.62 h +/- 11.25 respectively. Day 14 cure rates for the ITT and PP were 95.1% and 100% respectively while day 28 cure rates were 91.3% and 95.7% respectively. The overall PCR corrected day 28 cure rate was 95.1% for the ITT. The six-dose regimen of AL was well tolerated with no drug-related serious adverse events. Although six patients recorded a QTc prolongation of > 60 ms on D3 over D0 recording, no patient recorded a QTc interval > 500 ms. CONCLUSION: The six-dose regimen of AL tablets is safe and effective for the treatment of acute uncomplicated malaria in Nigerian infants and children weighing between five and 25 kg. TRIAL REGISTRATION: NCT00709969.

Congenital Heart Defects in Nigerian Children: Preliminary Data From the National Pediatric Cardiac Registry.

BACKGROUND: Congenital heart defects (CHDs) are common birth defects with significant impact on morbidity and mortality. We aimed to compare regional patterns of CHDs in Nigeria using a registry-based approach. METHODS: Children with echocardiography-confirmed CHDs at 17 medical centers across the country were enrolled in a pilot National Pediatric Cardiac Registry from January to December 2014. RESULTS: A total of 1,296 children (52.9% male; median age 0.9 years) with CHDs were enrolled. Patients enrolled in Northern Nigeria constituted 34.6% of the study population and were older compared to those enrolled from Southern Nigeria (2.9 ± 3.6 vs 2.4 ± 3.5 years; P = .02). Ventricular septal defects were significantly more prevalent in the North (37.4%) compared with the South (18.5%; P < .0001), while severe CHDs were more prevalent in the South ( P = .004). Of the 208 (16.0%) children who received corrective cardiac intervention, only 43 (20.7%) of them had the intervention done in country. More patients in the South received intervention compared to the North (19.02% vs 10.5%; P < .0001). CONCLUSION: This is the first prospective, registry-based, multicenter study of CHDs in Nigerian children. We demonstrate important differences between the Northern and the Southern geographical regions of the country in terms of age at diagnosis, type, and severity of lesion as well as access to cardiac surgery. The findings demonstrate the utility of a national CHDs registry for understanding clinical epidemiology of CHDs in low- and middle-income countries and its potential to serve as a basis for research and planning.

Audit of availability and distribution of paediatric cardiology services and facilities in Nigeria.

BACKGROUND: Paediatric cardiac services in Nigeria have been perceived to be inadequate but no formal documentation of availability and distribution of facilities and services has been done. OBJECTIVE: To evaluate and document the currently available paediatric cardiac services in Nigeria. METHODS: In this questionnaire-based, cross-sectional descriptive study, an audit was undertaken from January 2010 to December 2014, of the personnel and infrastructure, with their distributions according to geopolitical zones of Nigeria. RESULTS: Forty-eight centres participated in the study, with 33 paediatric cardiologists and 31 cardiac surgeons. Echocardiography, electrocardiography and pulse oximetry were available in 45 (93.8%) centres while paediatric intensive care units were in 23 (47.9%). Open-heart surgery was performed in six (12.5%) centres. South-West zone had the majority of centres (20; 41.7%). CONCLUSIONS: Available paediatric cardiac services in Nigeria are grossly inadequate and poorly distributed. Efforts should be intensified to upgrade existing facilities, establish new and functional centres, and train personnel.

Effects of malaria in pregnancy on newborn anthropometry.

BACKGROUND: Malaria in pregnancy remains a major cause of infant mortality through its contribution to preterm delivery, low birth weight and intrauterine death. METHODOLOGY: During a cross-sectional study of 983 mothers delivering in a secondary health care facility in Ibadan, southwestern Nigeria, an area of high malaria transmission, the effect of maternal and placental malaria parasitaemia on newborn anthropometry was evaluated. Malaria parasitemia was detected by microscopy of Giemsa stained thick blood smears. RESULTS: Placental, maternal and combined placental and maternal malaria parasitaemia rates at the time of delivery were 13.1%, 12.7% and 11.1% respectively. The geometric mean parasite densities in maternal and placental smears were significantly higher in primigravid mothers than others (p = 0.004 and 0.002 respectively). Low birth weight rate was higher among babies born to mothers with maternal parasitaemia compared to those without (8.0 % versus 6.3%, p < 0.05). The mean birth weight was lower in neonates of mothers with peripheral and placental parasitaemia by 138 g and 122 g (p = 0.01 and 0.02) respectively, while the respective difference was up to 168 g and 151 g among primigravidae (p = 0.03 and 0.04). Neonates of mothers with maternal and placental parasitaemia had a lower mean length than those without parasitaemia (48.2 vs 49.2cm, p = < 0.0001 and 48.5 vs 49.2cm p = 0.02 respectively). Occiptofrontal circumference and ponderal indices were not significantly affected by maternal malaria parasitaemia. CONCLUSION: Malaria in pregnancy results in symmetric foetal growth restriction and the effect is more marked among primigravid mothers.