Terrain-Enhanced Precipitation Processes Above the Melting Layer: Results From OLYMPEX.

Enhancement of precipitation processes aloft over complex terrain is documented using reflectivity data from an S-band scanning radar (NPOL) that was deployed on the west coast of Washington State during the Olympic Mountains Experiment (OLYMPEX). From November 2015 through mid-January 2016, NPOL obtained high-resolution data within sectors over the ocean and over the windward slopes of the Olympic Mountains. Contoured Frequency by Altitude Diagrams of radar reflectivity highlight a higher frequency of occurrence of larger reflectivities for all heights between 2 and 8 km over land compared to ocean, with the largest difference in the 4- to 6-km range indicating a robust signature of enhancement aloft over the windward slopes. This enhancement pattern is found to some degree under all environmental conditions considered but is especially pronounced during periods of high vapor transport, high melting level height, southwest low-level winds, and neutral stability. These conditions are generally associated with warm sectors of midlatitude cyclones and atmospheric rivers. Past studies have postulated that a secondary enhancement in reflectivity aloft was an intrinsic part of atmospheric river type systems. However, these results show that further significant enhancement of this signature occurs as deep moist-neutral, high water vapor content flow is lifted when it encounters a mountain range. Reflectivity data from the dual-precipitation radar aboard the Global Precipitation Measurement satellite also documents this reflectivity increase aloft over the Olympic Mountains compared to the adjacent ocean, showing the potential for Global Precipitation Measurement to provide reliable estimates of precipitation structure over remote mountainous regions.

Effects of the EQUIP quasi-experimental study testing a collaborative quality improvement approach for maternal and newborn health care in Tanzania and Uganda.

BACKGROUND: Quality improvement is a recommended strategy to improve implementation levels for evidence-based essential interventions, but experience of and evidence for its effects in low-resource settings are limited. We hypothesised that a systemic and collaborative quality improvement approach covering district, facility and community levels, supported by report cards generated through continuous household and health facility surveys, could improve the implementation levels and have a measurable population-level impact on coverage and quality of essential services. METHODS: Collaborative quality improvement teams tested self-identified strategies (change ideas) to support the implementation of essential maternal and newborn interventions recommended by the World Health Organization. In Tanzania and Uganda, we used a plausibility design to compare the changes over time in one intervention district with those in a comparison district in each country. Evaluation included indicators of process, coverage and implementation practice analysed with a difference-of-differences and a time-series approach, using data from independent continuous household and health facility surveys from 2011 to 2014. Primary outcomes for both countries were birth in health facilities, breastfeeding within 1 h after birth, oxytocin administration after birth and knowledge of danger signs for mothers and babies. Interpretation of the results considered contextual factors. RESULTS: The intervention was associated with improvements on one of four primary outcomes. We observed a 26-percentage-point increase (95% CI 25-28%) in the proportion of live births where mothers received uterotonics within 1 min after birth in the intervention compared to the comparison district in Tanzania and an 8-percentage-point increase (95% CI 6-9%) in Uganda. The other primary indicators showed no evidence of improvement. In Tanzania, we saw positive changes for two other outcomes reflecting locally identified improvement topics. The intervention was associated with an increase in preparation of clean birth kits for home deliveries (31 percentage points, 95% CI 2-60%) and an increase in health facility supervision by district staff (14 percentage points, 95% CI 0-28%). CONCLUSIONS: The systemic quality improvement approach was associated with improvements of only one of four primary outcomes, as well as two Tanzania-specific secondary outcomes. Reasons for the lack of effects included limited implementation strength as well a relatively short follow-up period in combination with a 1-year recall period for population-based estimates and a limited power of the study to detect changes smaller than 10 percentage points. TRIAL REGISTRATION: Pan African Clinical Trials Registry: PACTR201311000681314.

Quality of treatment for febrile illness among children at outpatient facilities in sub-Saharan Africa.

For the prompt and effective management of malaria cases (a key strategy for reducing the enormous burden of the disease), healthworkers must prescribe antimalarial drugs according to evidence-based guidelines. In sub-Saharan Africa, the guidelines for use in outpatient settings generally recommend that febrile illness in children should be suspected to be malaria and be treated with an antimalarial drug. The quality of treatment offered to febrile children at outpatient facilities in this region has now been investigated in a literature review. The results of five methodologically comparable studies were also used to explore the determinants of malaria-treatment practices. The quality of treatment prescribed to febrile children was found to have been generally sub-optimal, with low levels of adherence to national guidelines, the frequent selection of non-recommended antimalarials, and the use of incorrect dosages. Several factors might be to responsible for these shortcomings. Although interventions such as the Integrated Management of Childhood Illness (IMCI) strategy can lead to improvements, a better understanding of the practices of the healthworkers responsible for treating febrile children will be needed before treatment is made much better. The failure to provide treatment of good quality will become an increasingly important problem as antimalarial policies involving drugs with more complex dosing regimens, such as artemisinin-based combination therapies (ACT), are implemented. If the malaria burden in Africa is to be greatly reduced, the deployment of ACT must be accompanied by interventions to ensure the correct treatment of children at the point of care. Some interventions, such as IMCI, can improve the treatment of not only malaria but also other potentially life-threatening illnesses.

Predictors of the quality of health worker treatment practices for uncomplicated malaria at government health facilities in Kenya.

BACKGROUND: When replacing failing drugs for malaria with more effective drugs, an important step towards reducing the malaria burden is that health workers (HW) prescribe drugs according to evidence-based guidelines. Past studies have shown that HW commonly do not follow guidelines, yet few studies have explored with appropriate methods why such practices occur. METHODS: We analysed data from a survey of government health facilities in four Kenyan districts in which HW consultations were observed, caretakers and HW were interviewed, and health facility assessments were performed. The analysis was limited to children 2-59 months old with uncomplicated malaria. Treatment was defined as recommended (antimalarial recommended by national guidelines), a minor error (effective, but non-recommended antimalarial), or inappropriate (no effective antimalarial). RESULTS: We evaluated 1006 consultations performed by 135 HW at 81 facilities: 567 children received recommended treatment, 314 had minor errors, and 125 received inappropriate treatment (weighted percentages: 56.9%, 30.4%, and 12.7%). Multivariate logistic regression analysis revealed that programmatic interventions such as in-service malaria training, provision of guidelines and wall charts, and more frequent supervision were significantly associated with better treatment quality. However, neither in-service training nor possession of the guideline document showed an effect by itself. More qualified HW made more errors: both major and minor errors (but generally more minor errors) when second-line drugs were in stock, and more major errors when second-line drugs were not in stock. Child factors such as age and a main complaint of fever were also associated with treatment quality. CONCLUSIONS: Our results support the use of several programmatic strategies that can redress HW deficiencies in malaria treatment. Targeted cost-effectiveness trials would help refine these strategies and provide more precise guidance on affordable and effective ways to strengthen and maintain HW practices.

Management of childhood illness at health facilities in Benin: problems and their causes.

OBJECTIVES: To prepare for the implementation of Integrated Management of Childhood Illness (IMCI) in Benin, we studied the management of ill children younger than 5 years at outpatient health facilities. METHODS: We observed a representative sample of consultations; after each consultation, we interviewed caregivers and reexamined children. Health workers' performance was evaluated against IMCI guidelines. To identify determinants of performance, statistical modeling was performed and 6 focus groups with health workers were conducted to solicit their opinions. RESULTS: Altogether, 584 children were enrolled and 101 health workers were observed; 130 health workers participated in focus group discussions. Many serious deficiencies were found: incomplete assessment of children's signs and symptoms, incorrect diagnosis and treatment of potentially life-threatening illnesses, inappropriate prescription of dangerous sedatives, missed opportunities to vaccinate, and failure to refer severely ill children for hospitalization. Quantitative and qualitative analyses showed various health facility-, health worker-, caregiver-, and child-related factors as possible determinants of health worker performance. CONCLUSIONS: Action is urgently needed. Our results suggest that to improve health care delivery, interventions should target both the health system and the community level.

Community health worker performance in the management of multiple childhood illnesses: Siaya District, Kenya, 1997-2001.

OBJECTIVES: To characterize community health worker (CHW) performance using an algorithm for managing common childhood illnesses in Siaya District, Kenya, we conducted CHW evaluations in 1998, 1999, and 2001. METHODS: Randomly selected CHWs were observed managing sick outpatient and inpatient children at a hospital, and their management was compared with that of an expert clinician who used the algorithm. RESULTS: One hundred, 108, and 114 CHWs participated in the evaluations in 1998, 1999, and 2001, respectively. The proportions of children treated "adequately" (with an antibiotic, antimalarial, oral rehydration solution, or referral, depending on the child's disease classifications) were 57.8%, 35.5%, and 38.9%, respectively, for children with a severe classification and 27.7%, 77.3%, and 74.3%, respectively, for children with a moderate (but not severe) classification. CHWs adequately treated 90.5% of malaria cases (the most commonly encountered classification). CHWs often made mistakes assessing symptoms, classifying illnesses, and prescribing correct doses of medications. CONCLUSIONS: Deficiencies were found in the management of sick children by CHWs, although care was not consistently poor. Key reasons for the deficiencies appear to be guideline complexity and inadequate clinical supervision; other possible causes are discussed.

Stroke awareness among Georgia adults: epidemiology and considerations regarding measurement.

BACKGROUND: To design and evaluate interventions for reducing the impact of stroke in Georgia, we assessed knowledge of signs, risk factors, and burden of stroke. METHODS: Adults in Georgia were studied with a random digit dial telephone survey. RESULTS: Answering an unaided question, 39% of 602 respondents named > or =1 stroke warning sign. Awareness was considerably greater when assessed with prompted questions. Most respondents (70%) said they would call 911 if someone had a stroke; almost all (95%) considered stroke an emergency. Risk factor awareness ranged from 97% (previous stroke) to 69% (diabetes). Altogether, 6% reported having had a stroke; 48% reported a stroke in their family. CONCLUSIONS: Georgia adults have low awareness of stroke warning signs. Our findings underscore the importance of conducting an effective educational campaign. Furthermore, a need exists for questions on stroke awareness that approximate more closely the situation in which a person must identify a potential stroke.

Predictors of correct treatment of children with fever seen at outpatient health facilities in the Central African Republic.

To identify factors associated with improved performance of health care workers who treat ill children in developing countries, the authors analyzed a sample of consultations of children with malaria (defined as any fever) from a national health facility survey conducted in the Central African Republic from December 1995 to January 1996. Twenty-eight health care workers and 204 children were studied. A univariate analysis revealed the following significant predictors of correct treatment, as defined by the Central African malaria control program: high fever (odds ratio (OR) = 3.25, 95% confidence interval (CI): 1.47, 7.17); correct health care worker diagnosis (OR = 2.59, 95% CI: 1.39, 4.85); and the caregiver's reporting the child's fever to the health care worker (OR = 2.18, 95% CI: 1.32, 3.62). There was an unexpected inverse association between the presence of a fever treatment chart and correct treatment (OR = 0.19, 95% CI: 0.04, 0.91). Correct treatment was marginally associated with a longer consultation time (p value for trend = 0.058). Neither in-service training in the treatment of fever nor supervision was significantly associated with correct treatment. For child health programs to improve, targeted studies are needed to understand which factors, alone or in combination, improve health care worker performance.

Antimicrobial resistance of nasopharyngeal isolates of Streptococcus pneumoniae and Haemophilus influenzae from children in the Central African Republic.

BACKGROUND: To assist the Central African Republic (CAR) develop national guidelines for treating children with pneumonia, a survey was conducted to determine antimicrobial resistance rates of nasopharyngeal isolates of Streptococcus pneumoniae (SP) and Haemophilus influenzae (HI). Secondary purposes of the survey were to identify risk factors associated with carriage of a resistant isolate and to compare the survey methods of including only children with pneumonia vs. including all ill children. METHODS: A cross-sectional survey of 371 ill children was conducted at 2 outpatient clinics in Bangui, CAR. RESULTS: In all 272 SP isolates and 73 HI isolates were cultured. SP resistance rates to penicillin, trimethoprim-sulfamethoxazole (TMP-SMX), tetracycline and chloramphenicol were 8.8, 6.3, 42.3 and 9.2%, respectively. All penicillin-resistant SP isolates were intermediately resistant. HI resistance rates to ampicillin, TMP-SMX and chloramphenicol were 1.4, 12.3 and 0%, respectively. The most common SP serotypes/groups were 19, 14, 6 and 1; 49% of HI isolates were type b. History of antimicrobial use in the previous 7 days was the only factor associated with carriage of a resistant isolate. Resistance rates were similar among ill children regardless of whether they had pneumonia. CONCLUSIONS: Resistance rates were low for antimicrobials recommended by the World Health Organization for children with pneumonia. We recommended TMP-SMX as the first line treatment for pneumonia in CAR because of its low cost, ease of dosing and activity against malaria.

Clinical, virologic, and immunologic follow-up of convalescent Ebola hemorrhagic fever patients and their household contacts, Kikwit, Democratic Republic of the Congo. Commission de Lutte contre les Epidémies à Kikwit.

A cohort of convalescent Ebola hemorrhagic fever (EHF) patients and their household contacts (HHCs) were studied prospectively to determine if convalescent body fluids contain Ebola virus and if secondary transmission occurs during convalescence. Twenty-nine EHF convalescents and 152 HHCs were monitored for up to 21 months. Blood specimens were obtained and symptom information was collected from convalescents and their HHCs; other body fluid specimens were also obtained from convalescents. Arthralgias and myalgia were reported significantly more often by convalescents than HHCs. Evidence of Ebola virus was detected by reverse transcription-polymerase chain reaction in semen specimens up to 91 days after disease onset; however, these and all other non-blood body fluids tested negative by virus isolation. Among 81 initially antibody negative HHCs, none became antibody positive. Blood specimens of 5 HHCs not identified as EHF patients were initially antibody positive. No direct evidence of convalescent-to-HHC transmission of EHF was found, although the semen of convalescents may be infectious. The existence of initially antibody-positive HHCs suggests that mild cases of Ebola virus infection occurred and that the full extent of the EHF epidemic was probably underestimated.

Persistence and genetic stability of Ebola virus during the outbreak in Kikwit, Democratic Republic of the Congo, 1995.

Ebola virus persistence was examined in body fluids from 12 convalescent patients by virus isolation and reverse transcription-polymerase chain reaction (RT-PCR) during the 1995 Ebola hemorrhagic fever outbreak in Kikwit, Democratic Republic of the Congo. Virus RNA could be detected for up to 33 days in vaginal, rectal, and conjunctival swabs of 1 patient and up to 101 days in the seminal fluid of 4 patients. Infectious virus was detected in 1 seminal fluid sample obtained 82 days after disease onset. Sequence analysis of an RT-PCR fragment of the most variable region of the glycoprotein gene amplified from 9 patients revealed no nucleotide changes. The patient samples were selected so that they would include some from a suspected line of transmission with at least three human-to-human passages, some from 5 survivors and 4 deceased patients, and 2 from patients who provided multiple samples through convalescence. There was no evidence of different virus variants cocirculating during the outbreak or of genetic variation accumulating during human-to-human passage or during prolonged persistence in individual patients.

Clinical virology of Ebola hemorrhagic fever (EHF): virus, virus antigen, and IgG and IgM antibody findings among EHF patients in Kikwit, Democratic Republic of the Congo, 1995.

Ebola hemorrhagic fever (EHF) patients treated at Kikwit General Hospital during the 1995 outbreak were tested for viral antigen, IgG and IgM antibody, and infectious virus. Viral antigen could be detected in virtually all patients during the acute phase of illness, while antibody was not always detectable before death. Virus was also isolated from patients during the course of their febrile illness, but attempts to quantify virus in Vero E6 cells by standard plaque assay were often unsuccessful. IgG and IgM antibody appeared at approximately the same time after disease onset (8-10 days), but IgM persisted for a much shorter period among the surviving convalescent patients. IgG antibody was detectable in surviving patients through about 2 years after onset, the latest time that samples were obtained. Detection of Ebola virus antigens or virus isolation appears to be the most reliable means of diagnosis for patients with suspected acute EHF, since patients with this often-fatal disease (80% mortality) may not develop detectable antibodies before death.

Linking the integrated management of childhood illness (IMCI) and health information system (HIS) classifications: issues and options.

Differences in the terms used to classify diseases in the Integrated Management of Childhood Illness (IMCI) guidelines and for health information system (HIS) disease surveillance could easily create confusion among health care workers. If the equivalent terms in the two classifications are not clear to health workers who are following the guidelines, they may have problems in performing the dual activities of case management and disease surveillance. These difficulties could adversely affect an individual's performance as well as the overall effectiveness of the IMCI strategy or HIS surveillance, or both. We interviewed key informants to determine the effect of these differences between the IMCI and HIS classifications on the countries that were implementing the IMCI guidelines. Four general approaches for addressing the problem were identified: translating the IMCI classifications into HIS classifications; changing the HIS list to include the IMCI classifications; using both the IMCI and HIS classification systems at the time of consultations; and doing nothing. No single approach can satisfy the needs of all countries. However, if the short-term or medium-term goal of IMCI planners is to find a solution that will reduce the problem for health workers and is also easy to implement, the approach most likely to succeed is translation of IMCI classifications into HIS classifications. Where feasible, a modification of the health information system to include the IMCI classifications may also be considered.

PIP: An interview was conducted among key informants to determine the effect of the differences between the Integrated Management of Childhood Illness (IMCI) and health information system (HIS) classifications on countries that were implementing the IMCI guidelines. Differences in the terms used to classify diseases in the IMCI guidelines and for the HIS disease surveillance could easily create confusion among health care workers. If the equivalent terms in the two classifications are not clear to health workers who are following the guidelines, they may have problems in performing the dual activities of case management and disease surveillance. These difficulties could adversely affect an individual's performance as well as the overall effectiveness of the IMCI strategy or HIS surveillance or both. Four general approaches for addressing the problem were identified: 1) translating the IMCI classifications into HIS classifications; 2) changing the HIS list to include the IMCI classifications; 3) using both the IMCI and HIS classification systems at the time of consultations; 4) doing nothing. No single approach can satisfy the needs of all countries. However, if the short-term or medium-term goal of IMCI planners is to find a solution that will reduce the problem for health workers and would also be easy to implement, then the method most feasible is the translation of IMCI classifications into HIS classifications. A modification of the HIS to include the IMCI classifications may also be considered.