Unseen blindness, unheard deafness, and unrecorded death and disability: congenital rubella in Kumasi, Ghana.

OBJECTIVES: Although rubella serosusceptibility among women of reproductive age in West Africa ranges from 10% to 30%, congenital rubella syndrome has not been reported. In Ghana, rubella immunization and serologic testing are unavailable. Our objectives were to identify congenital rubella syndrome cases, ascertain rubella antibody seroprevalence during pregnancy, and recommend strategies for congenital rubella syndrome surveillance. METHODS: Congenital rubella syndrome cases were identified through prospective surveillance and retrospective surveys of hospital records. A rubella serosurvey of pregnant urban and rural women was performed. RESULTS: Eighteen infants born within a 5-month period met the congenital rubella syndrome case definitions, coinciding with a 9-fold increase in presentation of infantile congenital cataract. The congenital rubella syndrome rate for this otherwise unrecorded rubella epidemic was conservatively estimated to be 0.8 per 1000 live births. A postepidemic rubella immunity rate of 92.6% was documented among 405 pregnant women; susceptibility was significantly associated with younger age (P = .000) and ethnicity (northern tribes, P = .024). CONCLUSIONS: Congenital rubella syndrome occurs in Ghana but is not reported. Information about congenital rubella syndrome and rubella in sub-Saharan Africa is needed to evaluate inclusion of rubella vaccine in proposed measles control campaigns.

Glucose and lactate kinetics in children with severe malaria.

Children with severe malaria often present with lactic acidosis and hypoglycemia. Although both complications independently predict mortality, mechanisms underlying their development are poorly understood. To study these metabolic derangements we sequentially allocated 21 children with falciparum malaria and capillary lactate concentrations of 5 mmol/L or more to receive either quinine or artesunate as antimalarial therapy, and dichloroacetate or saline placebo for lactic acidosis. We then administered a primed infusion (90 min) of L-[3-13C1]sodium lactate and D-[6,6-D2]glucose to determine the kinetics of these substrates. The mean (SD) glucose disposal rate in all patients was 56 (16) micromol/kg x min, and the geometric mean (range) lactate disposal rate was 100 (66-177) micromol/kg x min. Glucose and lactate disposal rates were positively correlated (r = 0.62; P = 0.005). Artesunate was associated with faster parasite clearance, lower insulin/glucose ratios, and higher glucose disposal rates than quinine. Lactate disposal was positively correlated with plasma lactate concentrations (r = 0.66; P = 0.002) and time to recovery from coma (r = 0.82; P < 0.001; n = 15). Basal lactate disposal rates increased with dichloroacetate treatment. Elevated glucose turnover in severe malaria mainly results from enhanced anaerobic glycolysis. Quinine differs from artesunate in its effects on glucose kinetics. Increased lactate production is the most important determinant of lactic acidosis.

Five-year review of diarrheal disease cases admitted to a busy referral hospital in Ghana.

AIM: To evaluate successes in the clinical management of severe diarrheal diseases in a busy referral hospital in Ghana, four years after the introduction of the World Health Organization's protocol for the clinical management of diarrhea and the establishment of an oral rehydration therapy Corner. METHOD: Data on the cases of diarrheal diseases recorded in the hospital from 1992 to 1996 were collected and analyzed. RESULTS: The average overall diarrheal disease mortality over the period was around 20% with twice as much deaths among adults than among children. There was a tendency of decline in childhood mortality, whereas it was much less evident among the adults. The high mortality caused by diarrheal diseases in the hospital and the differences in adult and childhood mortality were related to the problems in case management that stemmed from diarrhea case management training of clinical staff with a bias towards the pediatric staff, and also from the loss of several trained staff members through transfers and other staff replacements within the hospital. There were similarities in the trend of admissions for adults and children over the period, which suggested a possible common etiology for severe diarrheal diseases recorded in the hospital. CONCLUSIONS: Diarrheal mortality in a busy referral hospital should be investigated regularly for lapses in management because some of these deaths may be prevented by simple interventions.

Plasma nitrogen oxides and blood lactate concentrations in Ghanaian children with malaria.

Nitric oxide is an important host defence molecule as well as being a mediator in many pathophysiological processes. To investigate its role in severe malaria, we measured plasma nitrate and nitrite concentrations in 70 children with malaria (54 with severe malaria) and 48 control subjects (33 with medical conditions and 15 surgical patients). We related these measurements to plasma lactate concentrations, an established marker of disease severity in malaria. Plasma lactate levels were significantly elevated in patients with deep coma (P = 0.0007) and those with a fatal outcome, but mean nitrogen oxide concentrations were not significantly different in the 2 outcome categories and were not related to depth of coma (P > 0.5). In patients whose cerebrospinal fluid (CSF) was examined, lactate concentrations were elevated in fatal cases (geometric mean 8.2 mmol/L, n = 5) compared with survivors (3.4 mmol/L, n = 13; P = 0.032); corresponding CSF nitrogen oxide concentrations were 10.7 microM in fatal cases compared with 12.5 microM in survivors (P = 0.5). Plasma nitrogen oxide concentrations were negatively correlated with admission parasitaemia (r = -0.41, n = 70; P < 0.0001). In our population, elevations of plasma lactate, but not nitrite or nitrate, reflected disease severity in malaria.

Cerebral malaria in children.

A retrospective chart review for the 1993 calendar year identified 187 children with cerebral malaria admitted to a large teaching hospital in central Ghana, West Africa. The most common clinical presentation was fever, sensorial depression and convulsions in young children experiencing their first episode of malaria. One-half had splenomegaly. Additional features, seen in decreasing frequency, were hepatomegaly, vomiting, abdominal pain and headache. Long term sequelae were identified in 9% and mortality in 6%. Risk factors for central nervous system disease were negative history for previous malaria (P < 0.005) and a high percentage of parasitemia (P < 0.001). Death or long term sequelae were associated with multiple seizures and prolonged sensorial depression. The incidence of malaria is currently increasing in Western Africa and young children are more likely than older children to develop severe disease.