A mathematical model to estimate the incidence of child wasting in Yemen.

INTRODUCTION: The ongoing civil war in Yemen has severely restricted imports of food and fuel, disrupted livelihoods and displaced millions, worsening already high pre-war levels of food insecurity. Paired with frequent outbreaks of disease and a collapsed health system, this has brought rates of wasting in children under five to the country's highest recorded levels, which continue to increase as the crisis worsens and aid becomes increasingly limited. In their planning of services to treat and prevent wasting in children, humanitarian agencies rely on a standard calculation to estimate the expected number of cases for the coming year, where incidence is estimated from prevalence and the average duration of an episode of wasting. The average duration of an episode of moderate and severe wasting is currently estimated at 7.5 months-a globally-used value derived from historical cohort studies. Given that incidence varies considerably by context-where food production and availability, treatment coverage and disease rates all vary-a single estimate cannot be applied to all contexts, and especially not a highly unstable crisis setting such as Yemen. While recent studies have aimed to derive context-specific incidence estimates in several countries, little has been done to estimate the incidence of both moderate and severe wasting in Yemen. METHODS: In order to provide context-specific estimates of the average duration of an episode, and resultingly, incidence correction factors for moderate and severe wasting, we have developed a Markov model. Model inputs were estimated using a combination of treatment admission and outcome records compiled by the Yemen Nutrition Cluster, 2018 and 2019 SMART surveys, and other estimates from the literature. The model derived estimates for the governorate of Lahj, Yemen; it was initialized using August 2018 SMART survey prevalence data and run until October 2019-the date of the subsequent SMART survey. Using a process of repeated model calibration, the incidence correction factors for severe wasting and moderate wasting were found, validating the resulting prevalence against the recorded value from the 2019 SMART survey. RESULTS: The average durations of an episode of moderate and severe wasting were estimated at 4.86 months, for an incidence correction factor k of 2.59, and 3.86 months, for an incidence correction factor k of 3.11, respectively. It was found that the annual caseload of moderate wasting was 36% higher and the annual caseload of severe wasting 58% higher than the originally-assumed values, estimated with k = 1.6. CONCLUSION: The model-derived incidence rates, consistent with findings from other contexts that a global incidence correction factor cannot be sufficient, allow for improved, context-specific estimates of the burden of wasting in Yemen. In crisis settings such as Yemen where funding and resources are extremely limited, the model's outputs holistically capture the burden of wasting in a way that may guide effective decision-making and may help ensure that limited resources are allocated most effectively.

Outcomes of Hospitalized Infants Aged One to Six Months in Relation to Different Anthropometric Indices - An Observational Cohort Study.

OBJECTIVES: Malnutrition in infants less than six months is increasingly recognized. However, the WHO criteria for identifying malnutrition have not been fully evaluated against the risk of in-patient mortality. The observational study was conducted to evaluate the predictability of in-patient mortality of different anthropometric criteria and combination of criteria in order to understand which diagnostic criteria or combination of criteria most accurately predict in-patient mortality. METHODS: Data from a cohort of infants aged one to six months, admitted to Kalawati Saran Children's Hospital, New Delhi between February and December 2018 was analyzed. The discriminatory ability of different anthropometric indexes [weight-for-age Z score (WAZ), weight-for-length Z score (WLZ) and mid-upper arm circumference (MUAC)] and their combinations to predict in-patient mortality was assessed using Receiver operating characteristic (ROC) curves. RESULTS: A total of 1813 infants aged one to six months were admitted during the 11 mo period, of which 107 (5.9%) died in the hospital. Of all admissions, 39.9%, 26% and 23.4% were severely underweight, severely wasted and severely stunted, respectively. WAZ < -3 was the most sensitive predictor of mortality [sensitivity: 74.8%; specificity: 62.3%; area under the curve (AUC): 0.69, 95% CI: 0.64-0.74]. CONCLUSIONS: WAZ < -3 was the most sensitive predictor out of all individual and combined parameters/indexes in identifying infants less than six months at high risk of mortality which suggests that, it should be used to identify at-risk infants between one to six months on admission to in-patient care. Children identified as falling into this category should be properly evaluated and treated during their in-patient stay.

Costs and cost-effectiveness of three point-of-use water treatment technologies added to community-based treatment of severe acute malnutrition in Sindh Province, Pakistan.

BACKGROUND: Severe acute malnutrition (SAM) is a major global public health concern. Despite the cost-effectiveness of treatment, ministries of health are often unable to commit the required funds which limits service coverage. OBJECTIVE: A randomised controlled trial was conducted in Sindh Province, Pakistan, to assess whether adding a point of use water treatment to the treatment of SAM without complications improved its cost-effectiveness. Three treatment strategies - chlorine disinfection (Aquatabs); flocculent disinfection (Procter and Gamble Purifier of Water [P&G PoW]) and Ceramic Filters - were compared to a standard SAM treatment protocol. METHODS: An institutional perspective was adopted for costing, considering the direct and indirect costs incurred by the provider. Combining the cost of SAM treatment and water treatment, an average cost per child was calculated for the combined interventions for each arm. The costs of water treatment alone and the incremental cost-effectiveness of each water treatment intervention were also assessed. RESULTS: The incremental cost-effectiveness ratio for Aquatabs was 24 US dollars (USD), making it the most cost-effective strategy. The P&G PoW arm was the next least expensive strategy, costing an additional 149 USD per additional child recovered, though it was also the least effective of the three intervention strategies. The Ceramic Filters intervention was the most costly strategy and achieved a recovery rate lower than the Aquatabs arm and marginally higher than the P&G PoW arm. CONCLUSIONS: This study found that the addition of a chlorine or flocculent disinfection point-of-use drinking water treatment intervention to the treatment of SAM without complications reduced the cost per child recovered compared to standard SAM treatment. To inform the feasibility of future implementation, further research is required to understand the costs of government implementation and the associated costs to the community and beneficiary household of receiving such an intervention in comparison with the existing SAM treatment protocol.

Evaluation of the cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by lady health workers as compared to an outpatient therapeutic feeding programme in Sindh Province, Pakistan.

BACKGROUND: Due to the limited evidence of the cost-effectiveness of Community Health Workers (CHW) delivering treatment for severe acute malnutrition (SAM), there is a need to better understand the costs incurred by both implementing institutions and beneficiary households. This study assessed the costs and cost-effectiveness of treatment for cases of SAM without complications delivered by government-employed Lady Health Workers (LHWs) and complemented with non-governmental organisation (NGO) delivered outpatient facility-based care compared with NGO delivered outpatient facility-based care only alongside a two-arm randomised controlled trial conducted in Sindh Province, Pakistan. METHODS: An activity-based cost model was used, employing a societal perspective to include costs incurred by beneficiaries and the wider community. Costs were estimated through accounting records, interviews and informal group discussions. Cost-effectiveness was assessed for each arm relative to no intervention, and incrementally between the two interventions, providing information on both absolute and relative costs and effects. RESULTS: The cost per child recovered in outpatient facility-based care was similar to LHW-delivered care, at 363 USD and 382 USD respectively. An additional 146 USD was spent per additional child recovered by outpatient facilities compared to LHWs. Results of sensitivity analyses indicated considerable uncertainty in which strategy was most cost-effective due to small differences in cost and recovery rates between arms. The cost to the beneficiary household of outpatient facility-based care was double that of LHW-delivered care. CONCLUSIONS: Outpatient facility-based care was found to be slightly more cost-effective compared to LHW-delivered care, despite the potential for cost-effectiveness of CHWs managing SAM being demonstrated in other settings. The similarity of cost-effectiveness outcomes between the two models resulted in uncertainty as to which strategy was the most cost-effective. Similarity of costs and effectiveness between models suggests that whether it is appropriate to engage LHWs in substituting or complementing outpatient facilities may depend on population needs, including coverage and accessibility of existing services, rather than be purely a consideration of cost. Future research should assess the cost-effectiveness of LHW-delivered care when delivered solely by the government. TRIAL REGISTRATION: NCT03043352 , ClinicalTrials.gov. Retrospectively registered.

Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali.

BACKGROUND: The Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care. METHODS: Activity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled. RESULTS: In the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility. CONCLUSIONS: This study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.

Quality of care of treatment for uncomplicated severe acute malnutrition provided by lady health workers in Pakistan.

OBJECTIVE: To assess the quality of care provided by lady health workers (LHW) managing cases of uncomplicated severe acute malnutrition (SAM) in the community. DESIGN: Cross-sectional quality-of-care study. SETTING: The feasibility of the implementation of screening and treatment for uncomplicated SAM in the community by LHW was tested in Sindh Province, Pakistan. An observational, clinical prospective multicentre cohort study compared the LHW-delivered care with the existing outpatient health facility model. SUBJECTS: LHW implementing treatment for uncomplicated SAM in the community. RESULTS: Oedema was diagnosed conducted correctly for 87·5 % of children; weight and mid upper-arm circumference were measured correctly for 60·0 % and 57·4 % of children, respectively. The appetite test was conducted correctly for 42·0 % of cases. Of all cases of SAM without complications assessed during the study, 68·0 % received the correct medical and nutrition treatment. The proportion of cases that received the correct medical and nutrition treatment and key counselling messages was 4·0 %. CONCLUSIONS: This quality-of-care study supports existing evidence that LHW are able to identify uncomplicated SAM, and a majority can provide appropriate nutrition and medical treatment in the community. However, the findings also show that their ability to provide the complete package with an acceptable level of care is not assured. Additional evidence on the impact of supervision and training on the quality of SAM treatment and counselling provided by LHW to children with SAM is required. The study has also shown that, as in other sectors, it is essential that operational challenges are addressed in a timely manner and that implementers receive appropriate levels of support, if SAM is to be treated successfully in the community.

Quality of care for treatment of uncomplicated severe acute malnutrition delivered by community health workers in a rural area of Mali.

An alternative Community-based Management of Acute Malnutrition model with community health workers (CHWs) delivering treatment for uncomplicated severe acute malnutrition (SAM) was piloted in Mali. The capacity of the CHWs to evaluate, classify, and treat cases of uncomplicated SAM, to provide nutritional counselling to caretakers of children receiving treatment for SAM, malaria, pneumonia or diarrhoea and to correctly refer cases of complicated SAM, was assessed. This was done using direct observation by trained enumerators of the management of SAM cases using checklists, re-diagnosing the cases admitted for treatment and reviewing admissions cards and registers. One hundred twenty-five cases, assessed and treated by the CHWs, were observed. The majority of children were correctly assessed for the presence of major clinical signs (cough, diarrhoea, fever, and vomiting; 97.6%), and similarly most children were checked for the presence of danger signs (95.2%). Mid-upper arm circumference was correctly assessed in 96.8% of children and oedema was correctly assessed in 78.4% (The composite indicator, which includes all essential tasks to provide high-quality treatment, was achieved in 79.5% of cases. This paper concludes that well-trained and supervised CHWs are capable of managing cases of uncomplicated SAM. This suggests that such a strategy is an opportunity to increase access to quality treatment in Mali for SAM cases. However, further evidence is required to ensure that this level of care can be achieved at scale.

A clinical companion to the NICE guide on bronchiolitis.

The National Institute for Health and Care Excellence (NICE) ( 2015 ) defines bronchiolitis as a lower respiratory tract infection affecting children under two years, peaking between three and six months. It affects about one in three infants in the first year of life, making it the most common respiratory infection in infants ( NICE 2015 , 2016 ). Of these infants, 2-3% will require admission to hospital ( NICE 2016 ). Respiratory syncytial virus (RSV) is the most common organism detected in the nasopharyngeal aspirate in hospitalised infants, although other viruses such as rhinovirus, parainfluenza virus, influenza virus, adenovirus and human metapneumovirus are increasingly being recognised ( Paul et al 2016 ). As most infants with bronchiolitis are managed at home, the data available from the literature is not reflective of the true incidence and may represent only the 'tip of the iceberg'.

Taking Severe Acute Malnutrition Treatment Back to the Community: Practical Experiences from Nutrition Coverage Surveys.

The community-based management of acute malnutrition treatment model was introduced to respond to the limited coverage of the inpatient model. Yet until the introduction of quick and low-cost approaches to measuring coverage, its reach was unknown. Once the Coverage Monitoring Network (CMN) had been created to roll out the routine measurement of direct coverage estimates to implementers, they found that programs were reaching only a third of cases. The barriers found to be limiting coverage were the result of the limited perceived value, and therefore focus, on the community. Therefore, the Network used the coverage assessment methodology as a way to encourage implementers to engage more fully with the community. By introducing small changes to the project cycle, specifically a participatory approach to assessments, program design and implementation, the CMN has changed the way implementers engage with the community. Instead of viewing them as passive receivers of services, they have shifted their perspective to view them as service delivery partners. The process provides implementers with a deeper understanding of the context while allowing the community to better understand the program, its challenges, and the identification of solutions. The Network observed implementers from Ministries of Health, and non-governmental organizations, adjusted their understanding and approach to service provision, which is critical if we are to see sustainable increases in program coverage. These experiences show that there is an appetite from implementers in multiple contexts for these practical and simple tools for re-engaging the community.

Early recognition and management of brain tumours in children.

Brain tumours comprise over one quarter of all childhood cancers in the UK and are the most common cause of cancer-related deaths in children. The presentation of brain tumours can vary substantially in children. The presenting symptoms are often similar to less serious conditions, and are often managed as such initially. Therefore, it can be difficult to diagnose brain tumours in children. An early diagnosis is usually associated with more effective treatment and improved health outcomes. The diagnostic interval between first presentation to a health professional and diagnosis for brain tumours in children has been shown to be three times longer in the UK than in other developed countries. As a result, the HeadSmart campaign launched a symptom card in 2011 to increase awareness of brain tumours in children among the general population and healthcare professionals, with the aim of reducing the diagnostic interval to 5 weeks. Nurses have an essential role in early recognition of brain tumours in children, and in providing care and support to the child and their family following a diagnosis.

NICE guidelines on bronchiolitis: a robust appraisal of current evidence.

Bronchiolitis is common in infants. Oxygen therapy, fluids and occasionally respiratory support remain the mainstay of treatment. The NICE guidelines are expected to streamline the management of bronchiolitis and minimize potentially harmful interventions. Further research to find other useful therapies is necessary.

Coverage of community-based management of severe acute malnutrition programmes in twenty-one countries, 2012-2013.

OBJECTIVE: This paper reviews coverage data from programmes treating severe acute malnutrition (SAM) collected between July 2012 and June 2013. DESIGN: This is a descriptive study of coverage levels and barriers to coverage collected by coverage assessments of community-based SAM treatment programmes in 21 countries that were supported by the Coverage Monitoring Network. Data from 44 coverage assessments are reviewed. SETTING: These assessments analyse malnourished populations from 6 to 59 months old to understand the accessibility and coverage of services for treatment of acute malnutrition. The majority of assessments are from sub-Saharan Africa. RESULTS: Most of the programmes (33 of 44) failed to meet context-specific internationally agreed minimum standards for coverage. The mean level of estimated coverage achieved by the programmes in this analysis was 38.3%. The most frequently reported barriers to access were lack of awareness of malnutrition, lack of awareness of the programme, high opportunity costs, inter-programme interface problems, and previous rejection. CONCLUSIONS: This study shows that coverage of CMAM is lower than previous analyses of early CTC programmes; therefore reducing programme impact. Barriers to access need to be addressed in order to start improving coverage by paying greater attention to certain activities such as community sensitisation. As barriers are interconnected focusing on specific activities, such as decentralising services to satellite sites, is likely to increase significantly utilisation of nutrition services. Programmes need to ensure that barriers are continuously monitored to ensure timely removal and increased coverage.

Management of febrile convulsion in children.

The causes of febrile convulsions are usually benign. Such convulsions are common in children and their long-term consequences are rare. However, other causes of seizures, such as intracranial infections, must be excluded before diagnosis, especially in infants and younger children. Diagnosis is based mainly on history taking, and further investigations into the condition are not generally needed in fully immunised children presenting with simple febrile convulsions. Treatment involves symptom control and treating the cause of the fever. Nevertheless, febrile convulsions in children can be distressing for parents, who should be supported and kept informed by experienced emergency department (ED) nurses. This article discusses the aetiology, clinical presentation, diagnosis and management of children with febrile convulsion, and best practice for care in EDs. It also includes a reflective case study to highlight the challenges faced by healthcare professionals who manage children who present with febrile convulsion.

Salivary IgA responses to prolonged intensive exercise following caffeine ingestion.

PURPOSE: Prolonged, intensive exercise is associated with a reduction in concentration and secretion of salivary IgA (s-IgA). Saliva composition and secretion are under autonomic nervous system control, and caffeine ingestion, a widespread practice among athletes for its ergogenic properties, is associated with increased sympathetic nervous system activation. Therefore, this study investigated the influence of caffeine ingestion on s-IgA responses to prolonged, intensive exercise. METHODS: In a randomized crossover design, 11 endurance-trained males cycled for 90 min at 70% VO2peak on two occasions, having ingested 6 mg x kg(-1) body mass of caffeine (CAF) or placebo (PLA) 1 h before exercise. Whole, unstimulated saliva samples were collected before treatment (baseline), preexercise, after 45 min of exercise (midexercise), immediately postexercise, and 1 h postexercise. Venous blood samples were collected from a subset of six of these subjects at baseline, preexercise, postexercise, and 1 h postexercise. RESULTS: An initial pilot study found that caffeine ingestion had no effect on s-IgA concentration, secretion rate, or saliva flow rate at rest. Serum caffeine concentration was higher on CAF than PLA at preexercise, postexercise, and 1 h postexercise (P < 0.001). Plasma epinephrine concentration was higher on CAF than PLA at pre- and postexercise (P < 0.05). s-IgA concentration was higher on CAF than PLA at mid- and postexercise (P < 0.01), and s-IgA secretion rate was higher on CAF than PLA at midexercise only (P < 0.02). Caffeine ingestion did not affect saliva flow rate. Saliva alpha-amylase activity and secretion rate were higher on CAF than PLA (main effect for trial, P < 0.05). CONCLUSIONS: These findings suggest that caffeine ingestion before intensive exercise is associated with elevated s-IgA responses during exercise, which may be related to increases in sympathetic activation.