Economic evaluation of artesunate and three quinine regimens in the treatment of severe malaria in children at the Ebolowa Regional Hospital-Cameroon: a cost analysis.

BACKGROUND: Severe malaria is a leading cause of morbidity and mortality in under-fives in sub-Saharan Africa. Recently quinine has been replaced by artesunate as the first-line drug in the treatment of severe malaria in Cameroon. Artesunate has been shown to be cost-effective in African children, but whether these findings are transferable to Cameroonian children remains to be explored. OBJECTIVES: To conduct a cost-analysis of four different regimens used in the treatment from the perspective of the healthcare payer. METHODS: An economic evaluation alongside a randomized comparative study was conducted in children aged 3 months to 15 years, admitted at the Ebolowa Regional Hospital with severe malaria due to Plasmodium falciparum. Patients were randomized to receive one of the four treatment alternatives. Group 1 (ARTES) received parenteral artesunate at 2.4 mg/kg at H0, H12, H24 and then once daily; Group 2 (QLD) received a loading dose of quinine base at 16.6 mg/kg followed 8 h later by an 8-hourly maintenance dose of 8.3 mg/kg quinine base; Group 3 (QNLD3) received 8.3 mg/kg quinine base every 8 h, and Group 4 (QNLD2) received 12.5 mg/kg quinine base every 12 h. The main outcome measure for effectiveness of treatment was the parasite reduction rate. Based on a healthcare perspective, an evaluation of direct medical costs was done, including costs of anti-malarials, nursing care materials, adjuvant treatment, laboratory investigations, hospitalisation and professional fees. Guided by a cost minimalization approach, the relative costs of these treatment alternatives was compared and reported. RESULTS: Overall cost was higher for ARTES group at $65.14 (95% CI $57.68-72.60) than for quinine groups ($52.49-$62.40), but the difference was not statistically significant. Cost of the anti-malarial drug was significantly higher for artesunate-treated patients than for quinine-treated patients, whereas cost of hospitalization was significantly lower for artesunate-treated patients than for quinine-treated patients. Incremental analysis of ARTES against QLD as a baseline resulted in an ICER of $46.8/PRR24 and suggests ARTES as the most cost effective of all four treatment options. CONCLUSION: Artesunate is a cost effective malaria treatment option relative to quinine alternatives with the lowest incremental cost per unit of effectiveness. Trial registration clinicaltrials.gov identifier: NCT02563704. Registered 19 September 2015, retrospectively registered.

A randomized trial of the efficacy of artesunate and three quinine regimens in the treatment of severe malaria in children at the Ebolowa Regional Hospital, Cameroon.

BACKGROUND: Severe malaria is a medical emergency with high mortality in children below 5 years of age especially in sub-Saharan Africa. Recently, quinine has been replaced by artesunate as the first-line drug in the treatment of severe malaria in Cameroon. No local data are yet available on the efficacy of artesunate with respect to the different quinine regimens used in this setting. This study was undertaken at the Ebolowa Regional Hospital (ERH), which is located in a region of perennial transmission of malaria. METHODS: This was a randomized, open-label trial in children aged 3 months to 15 years, admitted in the hospital with severe malaria due to Plasmodium falciparum confirmed on microscopy after informed parental consent. Patients were randomized into four groups. Group 1 (ARTES) received parenteral artesunate at 2.4 mg/kg at H0, H12, H24 and then once daily; Group 2 (QLD) received a loading dose of quinine base at 16.6 mg/kg followed 8 hours later by an eight-hourly maintenance dose of 8.3 mg/kg quinine base; Group 3 (QNLD3) received 8.3 mg/kg quinine base every 8 hours; and, Group 4 (QNLD2) received 12.5 mg/kg quinine base every 12 h. All patients invariably received a minimum of 24 h parenteral treatment, then, oral drugs were prescribed. The endpoints were fever clearance time, time to sit unsupported, time to eat, parasite clearance time, and parasitaemia reduction rate at H24. Survival analysis was used to compare the outcomes. RESULTS: One-hundred and sixteen patients completed the study: 29 in ARTES arm, 28 in QLD arm, 30 in QNLD3 arm, and 29 in QNLD2 arm. There was no major differences in baseline characteristics in the treatment groups. On analysis of endpoints, fever clearance time and parasite clearance time were significantly shorter for artesunate-treated patients than for quinine-treated patients. Parasitaemia reduction rate at H24 was also significantly higher for artesunate. Time to sit unsupported and time to eat were shorter with artesunate, but the difference was not statistically significant. CONCLUSION: Artesunate is more effective than quinine in the treatment of severe malaria in Cameroonian children.

Hydrocephalus in toddlers: the place of shunts in sub-Sahara African countries.

PURPOSE: This study describes the epidemiological patterns of hydrocephalus in toddlers in our setting in order to determine the proportion of those who could benefit from endoscopic third ventriculostomy (ETV). METHODS: This prospective and descriptive study included all toddlers operated on for hydrocephalus from 1 March 2008 to 31 March 2010 at the Yaounde Central Hospital. RESULTS: Forty-six toddlers were included representing 72% of all hydrocephalus cases managed at the Neurosurgery Unit during the study period. The mean age was 6.9 ± 1.6 months. The delay before treatment varied from 5 days to 15.8 months (mean = 3.7 ± 0.5 months). The commonest clinical presentation was macrocrania (78.3%). Of the toddlers, 58.7% presented with a probable blindness (loss of ocular pursuit); dilated and non-reactive pupils were found in nine patients (19.6%). The diagnosis was based on transfontanellar echography (TFE), CT scan or combined TFE and CT scan. Identified aetiologies were aqueduct stenosis (28.7%), haemorrhage (18%), Dandy-Walker's syndrome (14.3%), meningitis (10.8%), myelomeningocele (10.8%), agenesis of Monro's foramen (3.6%), brain abscess (3.2%) and posterior fossa tumour (3.6%). No specific cause was found in 7% of cases. The treatment was ventriculoperitoneal shunting in 42 cases (91.3%) and ETV in two cases (4.3%). Infections (11.1%) and shunts' obstruction (5.4%) were the main complications. CONCLUSION: Cases of hydrocephalus in toddlers are frequent in our setting. Regardless of the patient's age, the most prevailing aetiologies (infections, haemorrhage, myelomeningocele) and technological conditions (neuroendoscope) are less favourable for ETV. The use of ETV in the treatment of hydrocephalus in sub-Saharan Africa is still marginal and needs to be encouraged in selected cases. The prevention of non-tumoral hydrocephalus is of critical importance.

Risk factors for neonatal mortality at the yaounde gynaeco-obstetric and pediatric hospital, cameroon.

OBJECTIVE: Neonatal mortality is a major health problem in sub-Saharan Africa and the risk factors are not well established. The objective of this study was to determine the risk factors for neonatal mortality at the Yaounde Gynaeco-Obstetric and Pediatric Hospital. METHODS: We conducted a retrospective and analytic case-control study from the medical records of newborns admitted at the neonatal unit of this hospital between 1(st) March 2003 and 31(st) December 2012. 850 subjects were enrolled; that is 425 cases and 425 controls. Findings : The intra-hospital neonatal mortality rate was 9.83%. The main causes of neonatal mortality were in descending order: neonatal sepsis (60.2%), complications from prematurity (42.6%), birth asphyxia (37.4%), and congenital malformations (11.8%).The most prominent risk factors for neonatal mortality after multivariate analysis with logistic regression were: prolonged membrane rupture (OR: 3.8719, 95% CI: 2.3619-6.3471; P=0.0000), low birth weight (OR: 1.6240, 95% CI: 1.0108-2.6091; P=0.0450), Apgar score less than 7 at the 5th minute (OR: 6.8979, 95% CI: 4.0709-11.6883; P=0.0000), and congenital malformations (OR: 4.3307, 95% CI: 1.6120-11.6347; P=0.0037). Delivery by cesarean section (OR: 0.2644, 95% CI: 0.1478-0.4732; P=0.0000) and being born in this hospital (OR: 0.4409;95% CI: 0.2566-0.7576; P=0.0030) were protective. CONCLUSION: Neonatal mortality was influenced by both maternal and neonatal factors. This could be reduced through sensitization of pregnant women on the need of good quality antenatal visits, and capacitating the health personnel on the adequate management of high risk neonates.

Baseline demographic, clinical and immunological profiles of HIV-infected children at the Yaounde Gynaeco-Obstetric and Pediatric hospital, Cameroon.

INTRODUCTION: Approximately 2.5 million children below 15 years are infected with the HIV virus, with 90% in sub-Saharan Africa. The Yaounde Gynaeco-obstetric and Pediatric hospital has been a treatment center for HIV since 2006. The aim of this study was to analyze the baseline demographic, clinical and immunologic characteristics of the children with the HIV infection in this hospital. METHODS: It was a retrospective, cross- sectional and analytic study, carried out between January and April 2011 which included 61 HIV positive children aged 0-15 years. The socio-demographic, clinical and immunologic data were obtained from their medical records. RESULTS: Most (52.5%) of the children studied were above 60 months of age with a mean age of 71 months. Most (57.4%) were females. Mother-to-child transmission was the principal mode of contamination in 88.5% of cases. More than half of their mothers (55.7%) did not receive antiretroviral prophylaxis during pregnancy and labor. Common clinical findings included prolonged fever (44.6%), malnutrition (37.6%), lymphadenopathy (34.4%), respiratory tract infections (34.4%) and diarrhea (24.5%). Diagnosis was confirmed by HIV serology for most of the patients (93.4%). Polymerase chain reaction served as method of diagnosis in only 6.6% of the cases. HIV 1 was the predominant viral type. More than half of the children (52.5%) were seen at an advanced stage of the disease. CONCLUSION: HIV screening during pregnancy and prevention of mother-to-child transmission should be reinforced in this context, and fathers of HIV-infected children should be encouraged to go for HIV testing.

Neonatal mortality in a referral hospital in Cameroon over a seven year period: trends, associated factors and causes.

BACKGROUND: The fourth Millennium Development Goals targets reduction by 2/3 the mortality rate of under-fives by 2015. This reduction starts with that of neonatal mortality representing 40% of childhood mortality. In Cameroon neonatal mortality was 31‰ in 2011. OBJECTIVES: We assessed the trends, associated factors and causes of neonatal deaths at the Yaounde Gynaeco-Obstetric and Pediatric Hospital. METHODS: The study was a retrospective chart review. Data was collected from the hospital records, and included both maternal and neonatal variables from 1st January 2004 to 31st December 2010. RESULTS: The neonatal mortality was 10%. Out-borns represented 49.3% of the deceased neonates with 11.3% born at home. The neonatal mortality rate followed a downward trend dropping from 12.4% in 2004 to 7.2% in 2010. The major causes of deaths were: neonatal sepsis (37.85%), prematurity (31.26%), birth asphyxia (16%), and congenital malformations (10.54%). Most (74.2%) of the deaths occurred within the first week with 35% occurring within 24hours of life. Mortality was higher in neonates with birth weight less than 2500g and a gestational age of less than 37 weeks. In the mothers, it was high in single parenthood , primiparous and in housewives and students. CONCLUSION: There has been a steady decline of neonatal mortality since 2004. Neonatal sepsis, prematurity, birth asphyxia and congenital malformations were the major causes of neonatal deaths. Neonatal sepsis remained constant although at lower rates over the study period.

The spectrum of neurological disorders presenting at a neurology clinic in Yaoundé, Cameroon.

INTRODUCTION: The burden of these neurological diseases is higher in developing countries. However, there is a paucity and scarcity of literature on neurological diseases in sub-Saharan Africa. This study was therefore undertaken to determine the pattern of neurological diseases in this setting and then, compare to those elsewhere in the African continent and also serve as a baseline for planning and care for neurological disorders in Cameroon. METHODS: The study was conducted at the Clinique Bastos, in Yaoundé, city capital of Cameroon, centre region. Over a period of six years, all medical records were reviewed by a neurologist and neurological diagnoses classified according to ICD-10. RESULTS: Out of 4526 admissions 912 patients (20.15%) were given a neurological diagnosis. The most frequent neurological disorders were headache (31.9%), epilepsy (9.86%), intervertebral disc disorder (7.67%), followed by lumbar and cervical arthrosis, polyneuropathy, stroke, Parkinson disease and dementia. According to ICD-10 classification, Episodic and paroxysmal disorders (headaches, epilepsy, cerebrovascular, sleep disorders) were observed on 424 (46.48%) patients; followed by nerve, nerve root and plexus disorders in 115 (12.6%) patients. CONCLUSION: The above data emphasizes that neurological disease contributes substantially to morbidity in an urban African hospital. Headaches, epilepsy and intervertebral disc disorders are major causes of morbidity.

Risk factors for birth asphyxia in an urban health facility in cameroon.

OBJECTIVE: The World Health Organization (WHO) estimates that 4 million children are born with asphyxia every year, of which 1 million die and an equal number survive with severe neurologic sequelae. The purpose of this study was to identify the risk factors of birth asphyxia and the hospital outcome of affected neonates. MATERIALS & METHODS: This study was a prospective case-control study on term neonates in a tertiary hospital in Yaounde, with an Apgar score of < 7 at the 5th minute as the case group, that were matched with neonates with an Apgar score of ≥ 7 at the 5th minute as control group. Statistical analysis of relevant variables of the mother and neonates was carried out to determine the significant risk factors. RESULTS: The prevalence of neonatal asphyxia was 80.5 per 1000 live births. Statistically significant risk factors were the single matrimonial status, place of antenatal visits, malaria, pre-eclampsia/eclampsia, prolonged labor, arrest of labour, prolonged rupture of membranes, and non-cephalic presentation. Hospital mortality was 6.7%, that 12.2% of them had neurologic deficits and/or abnormal transfontanellar ultrasound/electroencephalogram on discharge, and 81.1% had a satisfactory outcome. CONCLUSION: The incidence of birth asphyxia in this study was 80.5% per1000 live birth with a mortality of 6.7%. Antepartum risk factors were: place of antenatal visit, malaria during pregnancy, and preeclampsia/eclampsia. Whereas prolonged labor, stationary labor, and term prolonged rupture of membranes were intrapartum risk faktors. Preventive measures during prenatal visits through informing and communicating with pregnant women should be reinforced.

The empiric use of palm kernel oil in neonatal skin care: justifiable or not?

Palm kernel oil is a vegetable oil derived from Elaeis guineensis and widely used in neonatal settings for skin care. It is a good emollient with a beneficial effect in moisturizing the skin and preventing transdermal heat and water loss. However, it's putative roles in the prevention or treatment of fatty acid defificiency is still controversial. So is its function in the improvement of neurological development from its longchain polyunsaturated fatty acids? We set out in this review to verify whether its empiric use in this context has any scientific justification and is recommendable. Although there is evidence that it has emollient and moisturizing properties necessary for softening the skin and restoring elasticity, controversy subsists on its other nutritional and neurodevelopmental properties.