Strengthening the Diagnosis and Treatment of Malnutrition Through Increased Nurse Involvement: A Quality Improvement Project From Pediatric Wards in Mozambique.

BACKGROUND: Childhood acute malnutrition continues to be a serious health problem in many low-resource settings in Africa. On pediatric wards in Mozambique, missed opportunities for timely diagnosis and treatment of malnutrition may lead to poor health outcomes. To improve inpatient nutritional care, a quality improvement (QI) project was implemented that aimed to engage pediatric nurses in inpatient malnutrition diagnosis and treatment. METHODS: In 2 Mozambican referral hospitals, for 6 months, the Plan-Do-Study-Act framework for QI was implemented to identify key drivers of the following measures: having complete anthropometric evaluation documented at admission, 3 or more weight measurements per hospitalization week, documentation of nutritional therapy for eligible patients, and documentation of referral for outpatient nutritional rehabilitation after discharge. Clinical data were abstracted from hospital charts and entered into an EpiInfo database, including a 3-month observation period after the project, and analyzed retrospectively. RESULTS: A total of 2,208 children from wards other than malnutrition were included in the analysis. Complete anthropometric evaluation at admission improved from 24.4% 2 months before the QI project to 80.1% during and 75.2% in the 3 months after the project (P<.001). The percentage of patients with 3 or more weight measurements per hospitalization week rose from 22.3% to 82.8% during and 75.0% after the project (P<.001). Documentation of nutritional therapy increased from 58.8% before to 67.1% during and 70.6% after the project (P=.54), and documentation of referral for outpatient nutritional rehabilitation after discharge decreased from 55.9% to 54.9% during and increased to 70.6% after the project, (P<.001). CONCLUSION: Nurse engagement may lead to important advancements in the diagnosis and treatment of acute malnutrition in pediatric wards other than malnutrition in Mozambique. Task-sharing, particularly nurse engagement, in combination with QI methodology, may be considered for wards in similar settings with a high burden of malnutrition.

Bubble CPAP respiratory support devices for infants in low-resource settings.

Approximately 46% of the 5.2 million annual under-5 deaths derive from neonatal conditions commonly associated with hypoxemia or acute respiratory distress. It has been estimated that 98% of these deaths occur in low- and middle-income countries (LMICs). Effective implementation of noninvasive respiratory support at all levels of healthcare could significantly reduce neonatal mortality. Several factors limit the widespread and effective implementation of noninvasive respiratory support in LMICs, including inadequate infrastructure, lack of proper instrumentation, shortage of skilled staff, costly disposables, and difficulties in the supply of consumables and spare parts. The aim of this state-of-the-art paper is to provide a detailed evaluation of the commercially available devices providing noninvasive respiratory support in LMICs, focusing on bubblecontinuous positive airway pressure (bCPAP). bCPAP might be administrated using a variety of different commercial devices, including devices specifically designed for LMICs, as well as using self-made systems. We described all the equipment required for safe and effective implementation of bCPAP, including air and oxygen sourced, pressure-reducing valves and flowmeters, air-oxygen blending systems, humidifiers, respiratory support devices, patient circuits, and airway interfaces. Specifically, we critically evaluated the advantages and disadvantages of various existing solutions within the context of low-resource settings.

Prognostic role of TOPS in ambulance-transferred neonates in a low-resource setting: a retrospective observational study.

BACKGROUND: Assessing the severity of transferred neonates at admission can improve resource allocation. This study evaluated the role of TOPS (illness severity score including temperature, oxygen saturation, skin perfusion and blood sugar) in predicting mortality in neonates transferred by ambulance in a low-resource setting. METHODS: The study was conducted at Beira Central Hospital (Mozambique). Infants who were transferred by ambulance to the Neonatal Intensive Care Unit between 16th June and 16th October 2021 were included. The association between TOPS and mortality was investigated with a logistic regression model. Receiver-operating characteristics (ROC) curve was derived for TOPS; area under the ROC curve, sensitivity and specificity were calculated. RESULTS: In-transport mortality was 2/198 (1.0%) and in-hospital mortality was 75/196 (38.3%). Median gestational age and birthweight were 38 weeks and 2600 g. Main causes of admission were asphyxia (29.3%), prematurity (25.3%) and sepsis (22.7%). Hypothermia and oxygen desaturation at admission were 75.8% and 32.3%. TOPS ≥ 1 was associated with increased mortality risk (odds ratio 7.06. 95% confidence interval 1.90 to 45.82), with 0.97 sensitivity and 0.26 specificity. CONCLUSIONS: The high mortality rate calls for interventions and quality initiative studies to improve the transfer process and the conditions at admission. TOPS can be used to identify neonates at risk of mortality and concentrate efforts of health care providers. Interventions preventing hypothermia and oxygen desaturation should be implemented in pre-transport stabilization and care during transport.

Successful management of generalized tetanus in a 12-year old girl without anti-tetanus immunoglobulins: a case report.

In low-income countries tetanus is a major public health concern owing to a low immunization coverage and unclean birth practices. Although it is a vaccine-preventable disease, tetanus can be contracted across the life course. The disease is prevalent and harmful in newborn babies and their mothers when the mothers` are unvaccinated against tetanus. We report on a case of a 12-year-old girl who presented with general malaise, anorexia, dysphagia, trismus and dehydration, which rapidly developed into severe generalized tetanus and was successfully managed in a low-resource setting without the availability of human anti-tetanus immunoglobulins.

Management of mothers and neonates in low resources setting during covid-19 pandemia.

The coronavirus disease (COVID-19) epidemic started in the Hubei province of China, but is rapidly spreading all over the world. Much of the information and literature have been centered on the adult population while a few reports pertaining to COVID-19 and neonates have been published so far. Actual guidelines are based on expert opinion and show significant differences among the official neonatal societies around the world. Recommendations for the care of neonates born to suspected or confirmed COVD-19 positive mothers in low-resource settings are very limited. This perspective aims to provide practical support for the planning of delivery, resuscitating, stabilizing, and providing postnatal care to an infant born to a mother with suspected or confirmed COVID-19 in low-resource settings where resources for managing emergency situations are limited.

HIV Encephalopathy in ART-Naïve, Hospitalized Infants in Mozambique.

INTRODUCTION: The neurodevelopmental impact of HIV infection in older children has been well-described, with characterization of HIV-associated encephalopathy (HIVE) and associated cognitive defects. HIVE is relatively common in older children who were vertically infected. The sparse literature on HIVE in infants suggests that incidence may be up to 10% in the first year of life, but no studies were identified that specifically evaluated hospitalized infants. METHODS: A descriptive study of routine inpatient data from two central referral hospitals in Mozambique was conducted. Inclusion criteria were infants with confirmed HIV infection aged <12 months, not on ART, admitted between 1 January 2019 and 30 June 2019. Presumptive HIVE was defined as having delayed developmental milestones in addition to microcephaly and/or pathological reflexes. RESULTS: Seven out of 27 patients (26%) were classified as presumptive HIVE. Delayed milestones were seen in 18 patients (67%) and the prevalence was approximately two times higher in the HIVE (+) group across all milestone categories. Delayed or no maternal ART (p = 0.03) and the infant not having received postnatal nevirapine prophylaxis (p = 0.02) were significantly associated with HIVE. CONCLUSIONS: HIVE prevalence is high in ART naïve hospitalized infants, particularly in those with risk factors for in-utero transmission. Thorough neurologic and developmental assessments can help identify HIV-infected infants and can be of particular utility in pediatric wards without access to point-of-care virologic testing where presumptive HIV diagnosis is still needed. Infants with HIVE need comprehensive care that includes antiretroviral therapy and physical/occupational therapy.

Midwives' Evaluation of a Neonatal Resuscitation in High- and Low-Resource Settings.

Aim: To assess midwives' evaluation of a real-life neonatal resuscitation and their opinion on importance of resuscitation interventions. Methods: Multicenter, multi-country study. Setting: Beira Central Hospital (Mozambique) and Azienda Ospedale-Università di Padova (Italy). Subjects: Sixteen Mozambican midwives and 18 Italian midwives. Interventions: Midwives' assessment was evaluated by using a predefined score, which graded each resuscitation intervention (0-2 points) and summed to a total score for each step (initial steps, bag-mask ventilation, and chest compressions). All scores were compared with referral scores given by two expert neonatologists. Results: Both Mozambican and Italian midwives overestimated their performance regarding of initial steps taken during resuscitation, chest compressions, high-oxygen concentrations (p < 0.01), and underestimated the importance of stimulation (p < 0.05). Mozambicans overestimated suctioning (p < 0.001). Participants agreed with experts about the importance of equipment preparation, using a warmer, drying the newborn, removing wet linen and heart rate assessment. Conclusion: Mozambican and Italian midwives overestimated the performance of a real-life neonatal resuscitation, with heterogeneous evaluation of the importance of several aspects of neonatal resuscitation. These findings may be useful for identifying educational goals.

Inpatient Point-of-Care HIV Early Infant Diagnosis in Mozambique to Improve Case Identification and Linkage to Antiretroviral Therapy.

INTRODUCTION: Novel approaches to case identification and linkage to antiretroviral therapy (ART) are needed to close gaps in early infant diagnosis (EID) of HIV. Point-of-care (POC) EID is a recent innovation that eliminates the long turnaround times of conventional EID that limit patient management in the inpatient setting. The initial deployment of POC EID in Mozambique focused primarily on outpatient clinics; however, 2 high-volume tier-4 pediatric referral hospitals were also included. METHODS: To assess the impact of inpatient POC EID, a retrospective review of testing and care data from Hospital Central de Beira (HCB) and Hospital Central de Maputo (HCM) was performed for the period September 2017 to July 2018, with comparison to the 8-month pre-POC period when dried blood spots were used for conventional EID. RESULTS: Monthly testing volume increased from 8.5 tests pre-POC to 17.6 tests with POC (P<.001). Among 511 children with POC testing, the median age was 5 months, there was ongoing breastfeeding in 326 (63.8%), and 136 (26.6%) of mothers and 146 (28.6%) of infants had not received ART or antiretroviral prophylaxis, respectively. POC tests were positive in 152 (29.7%) infants, and 52 (37.5%) had a previous negative DNA polymerase chain reaction through the conventional outpatient EID program. Linkage to ART for infants with HIV-positive tests improved 64% during the POC period (P=.002). Inpatient mortality for infected infants during the POC period was 28.2%. Excluding these deaths, 61.2% of eligible infants initiated ART as inpatients, but only 29.8% of those discharged without ART were confirmed to have initiated as outpatients. CONCLUSIONS: Inpatient wards are a high-yield site for EID and ART initiation that have historically been overlooked in programming for prevention of mother-to-child transmission. POC platforms represent a transformative opportunity to increase inpatient testing, make definitive diagnoses, and improve timely linkage to ART. Scale-up plans should prioritize pediatric wards.

Neonatal Intensive Care Unit Evacuation and Care During a Natural Disaster: The Experience of Cyclone Idai in Beira, Mozambique.

Global warming has increased the frequency of natural disasters, such as cyclones. Mozambique is considered one of the most vulnerable countries to extreme weather events. Natural disasters particularly affect vulnerable people, including preterm and critical ill infants of Neonatal Intensive Care Units (NICUs). Literature on NICU evacuations in the case of a natural disaster has been reported in high-resource settings, but it is lacking in low-resource settings. On the 14th of March 2019, a tropical cyclone (Idai) hit Mozambique. This report is a descriptive analysis of the experience of the NICU evacuation and care during and after cyclone Idai at Beira Central Hospital, Beira, Mozambique.

Impact of temperature change from admission to day one on neonatal mortality in a low-resource setting.

BACKGROUND: Thermal control after birth is an essential part of neonatal care. However, the relationship between neonatal temperature at and after admission is unknown. This study aimed to evaluate the change between neonatal temperature at admission and at day 1, and its impact on mortality. METHODS: Retrospective observational study at the Beira Central Hospital, Mozambique. Axillary temperatures were recorded at admission and at day 1 in 1,226 neonates who were admitted to the Special Care Unit between January 1 and December 31, 2017. The relationship between mortality rate and temperature change was evaluated with a matrix plot and a forest plot (obtained from a logistic regression model as odds ratios with 95% confidence intervals). RESULTS: Normothermia was found in 415 neonates (33.8%) at admission and in 638 neonates (52.0%) at day 1. Mortality rate was highest in (i) neonates who remained in severe/moderate hypothermia (74%), (ii) neonates who rewarmed from hypothermia (40-55%), and (iii) neonates who chilled to severe/moderate hypothermia (38-43%). Multivariable analysis confirmed that temperature change from admission to day 1 was an independent predictor of mortality (p < 0.0001). CONCLUSIONS: In a low-resource setting, one out of three neonates was found hypothermic at day 1 irrespectively of admission temperature. Relevant thermal deviations occurred in a high proportion of newborns with normothermia at admission. Being cold at admission and becoming cold or hyperthermic at day 1 were associated with increased likelihood of mortality. Appropriate actions to prevent both hypothermia and hyperthermia represent both a challenge and a priority during postnatal period.

Epidemiology of Disease and Mortality From a PICU in Mozambique.

OBJECTIVES: Delivery of pediatric critical care in low-income countries is limited by a lack of infrastructure, resources, and providers. Few studies have analyzed the epidemiology of disease associated with a PICU in a low-income country. The aim of this study was to document the primary diagnoses and the associated mortality rates of patients presenting to a tertiary PICU in Mozambique in order to formulate quality improvement projects through an international academic partnership. We hypothesized that the PICU mortality rate would be high and that sepsis would be a common cause of death. DESIGN: Retrospective, observational study. SETTING: Tertiary academic PICU. PATIENTS: All admitted PICU patients. INTERVENTIONS: All available data collection forms containing demographic and clinical data of patients admitted to the PICU at Hospital Central de Maputo, Mozambique from January 2013 to December 2013 were analyzed retrospectively. MEASUREMENTS AND MAIN RESULTS: The patient median age was 2 years (57% male). The most common primary diagnoses were malaria (22%), sepsis (18%), respiratory tract infections (12%), and trauma (6%). The mortality rate was 25%. Mortality rates were highest among patients with sepsis (59%), encephalopathy (56%), noninfectious CNS pathologies (33%), neoplastic diseases (33%), meningitis/encephalitis (29%), burns (26%), and cardiovascular pathologies (26%). The median length of PICU stay was 2 days. HIV exposure/infection had a nonstatistically significant association with mortality. Patients admitted for burns had the highest median length of PICU stay (4 d). Most trauma admissions were male (75%), and approximately half of all trauma admissions had an associated head injury (55%). CONCLUSIONS: Infectious disease and trauma were highly represented in this Mozambican PICU, and overall mortality was high compared with high-income countries. With this knowledge, targeted collaborative projects in Mozambique can now be created and modified. Further research is needed to monitor the potential benefits of such interventions.

Plasma concentration of parasite DNA as a measure of disease severity in falciparum malaria.

In malaria-endemic areas, Plasmodium falciparum parasitemia is common in apparently healthy children and severe malaria is commonly misdiagnosed in patients with incidental parasitemia. We assessed whether the plasma Plasmodium falciparum DNA concentration is a useful datum for distinguishing uncomplicated from severe malaria in African children and Asian adults. P. falciparum DNA concentrations were measured by real-time polymerase chain reaction (PCR) in 224 African children (111 with uncomplicated malaria and 113 with severe malaria) and 211 Asian adults (100 with uncomplicated malaria and 111 with severe malaria) presenting with acute falciparum malaria. The diagnostic accuracy of plasma P. falciparum DNA concentrations in identifying severe malaria was 0.834 for children and 0.788 for adults, similar to that of plasma P. falciparum HRP2 levels and substantially superior to that of parasite densities (P < .0001). The diagnostic accuracy of plasma P. falciparum DNA concentrations plus plasma P. falciparum HRP2 concentrations was significantly greater than that of plasma P. falciparum HRP2 concentrations alone (0.904 for children [P = .004] and 0.847 for adults [P = .003]). Quantitative real-time PCR measurement of parasite DNA in plasma is a useful method for diagnosing severe falciparum malaria on fresh or archived plasma samples.

Diagnosis, clinical presentation, and in-hospital mortality of severe malaria in HIV-coinfected children and adults in Mozambique.

BACKGROUND: Severe falciparum malaria with human immunodeficiency virus (HIV) coinfection is common in settings with a high prevalence of both diseases, but there is little information on whether HIV affects the clinical presentation and outcome of severe malaria. METHODS: HIV status was assessed prospectively in hospitalized parasitemic adults and children with severe malaria in Beira, Mozambique, as part of a clinical trial comparing parenteral artesunate versus quinine (ISRCTN50258054). Clinical signs, comorbidity, complications, and disease outcome were compared according to HIV status. RESULTS: HIV-1 seroprevalence was 11% (74/655) in children under 15 years and 72% (49/68) in adults with severe malaria. Children with HIV coinfection presented with more severe acidosis, anemia, and respiratory distress, and higher peripheral blood parasitemia and plasma Plasmodium falciparum histidine-rich protein-2 (PfHRP2). During hospitalization, deterioration in coma score, convulsions, respiratory distress, and pneumonia were more common in HIV-coinfected children, and mortality was 26% (19/74) versus 9% (53/581) in uninfected children (P < .001). In an age- and antimalarial treatment-adjusted logistic regression model, significant, independent predictors for death were renal impairment, acidosis, parasitemia, and plasma PfHRP2 concentration. CONCLUSIONS: Severe malaria in HIV-coinfected patients presents with higher parasite burden, more complications, and comorbidity, and carries a higher case fatality rate. Early identification of HIV coinfection is important for the clinical management of severe malaria.

Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial.

BACKGROUND: Severe malaria is a major cause of childhood death and often the main reason for paediatric hospital admission in sub-Saharan Africa. Quinine is still the established treatment of choice, although evidence from Asia suggests that artesunate is associated with a lower mortality. We compared parenteral treatment with either artesunate or quinine in African children with severe malaria. METHODS: This open-label, randomised trial was undertaken in 11 centres in nine African countries. Children (<15 years) with severe falciparum malaria were randomly assigned to parenteral artesunate or parenteral quinine. Randomisation was in blocks of 20, with study numbers corresponding to treatment allocations kept inside opaque sealed paper envelopes. The trial was open label at each site, and none of the investigators or trialists, apart from for the trial statistician, had access to the summaries of treatment allocations. The primary outcome measure was in-hospital mortality, analysed by intention to treat. This trial is registered, number ISRCTN50258054. FINDINGS: 5425 children were enrolled; 2712 were assigned to artesunate and 2713 to quinine. All patients were analysed for the primary outcome. 230 (8·5%) patients assigned to artesunate treatment died compared with 297 (10·9%) assigned to quinine treatment (odds ratio [OR] stratified for study site 0·75, 95% CI 0·63-0·90; relative reduction 22·5%, 95% CI 8·1-36·9; p=0·0022). Incidence of neurological sequelae did not differ significantly between groups, but the development of coma (65/1832 [3·5%] with artesunate vs 91/1768 [5·1%] with quinine; OR 0·69 95% CI 0·49-0·95; p=0·0231), convulsions (224/2712 [8·3%] vs 273/2713 [10·1%]; OR 0·80, 0·66-0·97; p=0·0199), and deterioration of the coma score (166/2712 [6·1%] vs 208/2713 [7·7%]; OR 0·78, 0·64-0·97; p=0·0245) were all significantly less frequent in artesunate recipients than in quinine recipients. Post-treatment hypoglycaemia was also less frequent in patients assigned to artesunate than in those assigned to quinine (48/2712 [1·8%] vs 75/2713 [2·8%]; OR 0·63, 0·43-0·91; p=0·0134). Artesunate was well tolerated, with no serious drug-related adverse effects. INTERPRETATION: Artesunate substantially reduces mortality in African children with severe malaria. These data, together with a meta-analysis of all trials comparing artesunate and quinine, strongly suggest that parenteral artesunate should replace quinine as the treatment of choice for severe falciparum malaria worldwide. FUNDING: The Wellcome Trust.