Eric D. McCollum

Task Shifting Routine Inpatient Pediatric HIV Testing Improves Program Outcomes in Urban Malawi: A Retrospective Observational Study

Background This study evaluated two models of routine HIV testing of hospitalized children in a high HIV-prevalence resource-constrained African setting. Both models incorporated “task shifting,” or the allocation of tasks to the least-costly, capable health worker. Methods and Findings Two models were piloted for three months each within the pediatric department of a referral hospital in Lilongwe, Malawi between January 1 and June 30, 2008. Model 1 utilized lay counselors for HIV testing instead of nurses and clinicians. Model 2 further shifted program flow and advocacy responsibilities from counselors to volunteer parents of HIV-infected children, called “patient escorts.” A retrospective review of data from 6318 hospitalized children offered HIV testing between January-December 2008 was conducted. The pilot quarters of Model 1 and Model 2 were compared, with Model 2 selected to continue after the pilot period. There was a 2-fold increase in patients offered HIV testing with Model 2 compared with Model 1 (43.1% vs 19.9%, p<0.001). Furthermore, patients in Model 2 were younger (17.3 vs 26.7 months, p<0.001) and tested sooner after admission (1.77 vs 2.44 days, p<0.001). There were no differences in test acceptance or enrollment rates into HIV care, and the program trends continued 6 months after the pilot period. Overall, 10244 HIV antibody tests (4779 maternal; 5465 child) and 453 DNA-PCR tests were completed, with 97.8% accepting testing. 19.6% of all mothers (n = 1112) and 8.5% of all children (n = 525) were HIV-infected. Furthermore, 6.5% of children were HIV-exposed (n = 405). Cumulatively, 72.9% (n = 678) of eligible children were evaluated in the hospital by a HIV-trained clinician, and 68.3% (n = 387) successfully enrolled into outpatient HIV care. Conclusions/Significance The strategy presented here, task shifting from lay counselors alone to lay counselors and patient escorts, greatly improved program outcomes while only marginally increasing operational costs. The wider implementation of this strategy could accelerate pediatric HIV care access in high-prevalence settings.

Superior uptake and outcomes of early infant diagnosis of HIV services at an immunization clinic versus an "under-five" general pediatric clinic in Malawi.

Objective: Although the Malawian government recommends HIV-exposed infants receive early infant diagnosis (EID) of HIV at “under-five” pediatric clinics (U5Cs), most never enroll. Therefore, we evaluated the integration of EID testing into an immunization clinic (IC) compared with the current standard of EID testing at an U5C. Design: Prospective observational study. Methods: Using routine provider-initiated HIV testing and counseling (PITC) registers, we prospectively studied 1757 children offered PITC at a government IC and U5C. Infants tested by HIV DNA polymerase chain reaction (PCR) were followed until PCR result disclosure or defaulting. Results: We sampled 877 and 880 consecutive PITC recipients at U5C and IC, respectively. Overall, a 7-fold greater proportion received PITC at IC (84.2% vs. 11.4%, P < 0.001). PITC recipients at IC were more than 14 months younger (2.6 vs. 17.0, P < 0.001), with greater proportions HIV exposed (17.6% vs. 5.3%, P < 0.001) and PCR eligible (7.9% vs. 3.5%, P < 0.001). A higher percentage of IC infants accepted PCR testing (100.0% vs. 90.3%, P = 0.03). Additionally, IC PCR recipients were 2.5 months younger (3.1 vs. 5.6, P < 0.001) with 4 times less testing PCR positive (7.1% vs. 32.1%, P < 0.001). Importantly, a more than 3-fold greater proportion of HIV-exposed infants at IC returned for their PCR result and enrolled into care (78.6% vs. 25.0%, P < 0.001). Conclusions: Compared with an U5C, integrating EID testing into an IC is more acceptable, more feasible, enrolls more infants into EID at younger ages, and would likely strengthen Malawis EID services if expanded.

Pneumonia and Malnutrition are Highly Predictive of Mortality among African Children Hospitalized with Human Immunodeficiency Virus Infection or Exposure in the Era of Antiretroviral Therapy

OBJECTIVE To identify clinical characteristics predicting death among inpatients who are infected with or exposed to human immunodeficiency virus (HIV) during a period of pediatric antiretroviral therapy scale-up in sub-Saharan Africa. STUDY DESIGN Retrospective review of medical records from every child with HIV infection (n = 834) or exposure (n = 351) identified by routine inpatient testing in Kamuzu Central Hospital, Lilongwe, Malawi, September 2007 through December 2008. RESULTS The inpatient mortality rate was high among children with HIV infection (16.6%) and exposure (13.4%). Clinically diagnosed Pneumocystis pneumonia or very severe pneumonia independently predicted death in inpatients with HIV infection (OR 14; 95% CI 8.2 to 23) or exposure (OR 21; CI 8.4 to 50). Severe acute malnutrition independently predicted death in children who are HIV infected (OR 2.2; CI 1.7 to 3.9) or exposed (OR 5.1; CI 2.3 to 11). Other independent predictors of death were septicemia, Kaposi sarcoma, meningitis, and esophageal candidiasis for children infected with HIV, and meningitis and severe anemia for inpatients exposed to HIV. CONCLUSIONS Severe respiratory tract infections and malnutrition are both highly prevalent and strongly associated with death among hospitalized children who are HIV infected or exposed. Novel programmatic and therapeutic strategies are urgently needed to reduce the high mortality rate among inpatients with HIV infection and HIV exposure in African pediatric hospitals.

Routine inpatient human immunodeficiency virus testing system increases access to pediatric human immunodeficiency virus care in sub-Saharan Africa.

Background: Routine Human Immunodeficiency Virus (HIV) testing, called provider-initiated opt-out HIV testing and counseling (PITC), is recommended in African countries with high HIV prevalence. However, it is unknown whether PITC increases access to pediatric HIV care. In 2008, the Baylor International Pediatric AIDS Initiative implemented PITC (BIPAI-PITC) at a Malawian hospital. We sought to evaluate the influence of BIPAI-PITC, compared with nonroutine HIV testing (NRT), on pediatric HIV care access. Methods: Retrospective data from 7077 pediatric inpatients were collected during sequential 4-month periods of NRT and BIPAI-PITC. In-hospital and 1-year outcomes for 337 HIV-infected and HIV-exposed uninfected inpatients not previously enrolled in HIV care were analyzed to assess the clinical influence of each testing strategy. Results: During BIPAI-PITC, a greater proportion of all hospitalized children received HIV testing (81.0% vs. 33.3%, P < 0.001), accessed inpatient HIV-trained care (7.5% vs. 2.4%, P < 0.001), enrolled into an outpatient HIV clinic after discharge (3.2% vs. 1.3%, P < 0.001), and initiated antiretroviral therapy (ART) after hospitalization (1.1% vs. 0.6%, P = 0.010) compared with NRT. Additionally, BIPAI-PITC increased the proportion of hospitalized HIV-infected and HIV-exposed uninfected children receiving DNA polymerase chain reaction testing (73.5% vs. 35.2%, P < 0.001), but did not improve outpatient enrollment or ART initiation of identified HIV-infected patients. Conclusions: BIPAI-PITC increases access to inpatient and outpatient pediatric HIV care for hospitalized children, including DNA polymerase chain reaction testing and ART. Broader implementation of BIPAI-PITC or similar approaches, along with more pediatric HIV-trained clinicians and improved defaulter-tracking methods, would improve pediatric HIV service utilization globally.

Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001–12: a retrospective observational study

BACKGROUND Few studies have reported long-term data on mortality rates for children admitted to hospital with pneumonia in Africa. We examined trends in case fatality rates for all-cause clinical pneumonia and its risk factors in Malawian children between 2001 and 2012. METHODS Individual patient data for children (<5 years) with clinical pneumonia who were admitted to hospitals participating in Malawis Child Lung Health Programme between 2001 and 2012 were recorded prospectively on a standardised medical form. We analysed trends in pneumonia mortality and childrens clinical characteristics, and we estimated the association of risk factors with case fatality for children younger than 2 months, 2-11 months of age, and 12-59 months of age using separate multivariable mixed effects logistic regression models. FINDINGS Between November, 2012, and May, 2013, we retrospectively collected all available hard copies of yellow forms from 40 of 41 participating hospitals. We examined 113 154 pneumonia cases, 104 932 (92·7%) of whom had mortality data and 6903 of whom died, and calculated an overall case fatality rate of 6·6% (95% CI 6·4-6·7). The case fatality rate significantly decreased between 2001 (15·2% [13·4-17·1]) and 2012 (4·5% [4·1-4·9]; ptrend<0·0001). Univariable analyses indicated that the decrease in case fatality rate was consistent across most subgroups. In multivariable analyses, the risk factors significantly associated with increased odds of mortality were female sex, young age, very severe pneumonia, clinically suspected Pneumocystis jirovecii infection, moderate or severe underweight, severe acute malnutrition, disease duration of more than 21 days, and referral from a health centre. Increasing year between 2001 and 2012 and increasing age (in months) were associated with reduced odds of mortality. Fast breathing was associated with reduced odds of mortality in children 2-11 months of age. However, case fatality rate in 2012 remained high for children with very severe pneumonia (11·8%), severe undernutrition (15·4%), severe acute malnutrition (34·8%), and symptom duration of more than 21 days (9·0%). INTERPRETATION Pneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specific subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of sufficient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of effective national systems for data collection. Further work combining this with data on trends in the incidence of pneumonia in the community are needed to estimate trends in the overall risk of mortality from pneumonia in children in Malawi. FUNDING Bill & Melinda Gates Foundation.

Task shifting an inpatient triage, assessment and treatment programme improves the quality of care for hospitalised Malawian children

We aimed to improve paediatric inpatient surveillance at a busy referral hospital in Malawi with two new programmes: (i) the provision of vital sign equipment and implementation of an inpatient triage programme (ITAT) that includes a simplified paediatric severity‐of‐illness score, and (ii) task shifting ITAT to a new cadre of healthcare workers called ‘vital sign assistants’ (VSAs).

Development of a severity of illness scoring system (inpatient triage, assessment and treatment) for resource-constrained hospitals in developing countries

To develop a new paediatric illness severity score, called inpatient triage, assessment and treatment (ITAT), for resource‐limited settings to identify hospitalised patients at highest risk of death and facilitate urgent clinical re‐evaluation.

Determining the quality of IMCI pneumonia care in Malawian children

Abstract Background: Although pneumonia is the leading cause of child mortality worldwide, little is known about the quality of routine pneumonia care in high burden settings like Malawi that utilize World Health Organizations Integrated Management of Childhood Illnesses (IMCI) guidelines. Due to severe human resource constraints, the majority of clinical care in Malawi is delivered by non-physician clinicians called Clinical Officers (COs). Aim: To assess the quality of child pneumonia care delivered by Malawian COs in routine care conditions. Methods: At an outpatient district-level clinic in Lilongwe, Malawi, 10 COs caring for 695 children who presented with fever, cough, or difficulty breathing were compared to IMCI pneumonia diagnostic and treatment guidelines. Results: Fewer than 1% of patients received an evaluation by COs that included all 16 elements of the history and physical examination. The respiratory rate was only determined in 16·1% of patients presenting with cough or difficulty breathing. Of the 274 children with IMCI-defined pneumonia, COs correctly diagnosed 30%, and administered correct pneumonia care in less than 25%. COs failed to hospitalize 40·8% of children with severe or very severe pneumonia. Conclusions: IMCI pneumonia care quality at this Malawian government clinic is alarmingly low. Along with reassessing current pneumonia training and supervision approaches, novel quality improvement interventions are necessary to improve care.

Multicenter study of hypoxemia prevalence and quality of oxygen treatment for hospitalized Malawian children

BACKGROUND Although hypoxemic children have high mortality, little is known about hypoxemia prevalence and oxygen administration in African hospitals. We aimed to determine the hypoxemia prevalence and quality of oxygen treatment by local clinicians for hospitalized Malawian children. METHODS The study was conducted in five Malawian hospitals during January-April 2011. We prospectively measured the peripheral oxygen saturation (SpO(2)) using pulse oximetry for all children <15 years old and also determined clinical eligibility for oxygen treatment using WHO criteria for children <5 years old. We determined oxygen treatment quality by Malawian clinicians by comparing their use of WHO criteria for patients <5 years old using two standards: hypoxemia (SpO(2) <90%) and the use of WHO criteria by study staff. RESULTS Forty of 761 (5.3%) hospitalized children <15 years old had SpO(2) <90%. No hospital used pulse oximetry routinely, and only 9 of 40 (22.5%) patients <15 years old with SpO(2) <90% were treated with oxygen by hospital staff. Study personnel using WHO criteria for children <5 years old achieved a higher sensitivity (40.0%) and lower specificity (82.7%) than Malawian clinicians (sensitivity 25.7%, specificity 94.1%). CONCLUSION Although hypoxemia is common, the absence of routine pulse oximetry results in most hospitalized, hypoxemic Malawian children not receiving available oxygen treatment.

Non-invasive ventilation with bubble CPAP is feasible and improves respiratory physiology in hospitalised Malawian children with acute respiratory failure

Background: In low-income countries and those with a high prevalence of HIV, respiratory failure is a common cause of death in children. However, the role of non-invasive ventilation with bubble continuous positive airway pressure (bCPAP) in these patients is not well established. Methods:A prospective observational study of bCPAP was undertaken between July and September 2012 in 77 Malawian children aged 1 week to 14 years with progressive acute respiratory failure despite oxygen and antimicrobial therapy. Results:Forty-one (53%) patients survived following bCPAP treatment, and an HIV-uninfected single-organ disease subgroup demonstrated bCPAP success in 14 of 17 (82%). Compared with children aged ≧60 months, infants of 0–2 months had a 93% lower odds of bCPAP failure (odds ratio 0·07, 95% confidence interval 0·004–1·02, P  =  0·05). Following commencement of bCPAP, respiratory physiology improved, the average respiratory rate decreased from 61 to 49 breaths/minute (P  =  0·0006), and mean oxygen saturation increased from 92·1% to 96·1% (P  =  0·02). Conclusions:bCPAP was well accepted by caregivers and patients and can be feasibly implemented into a tertiary African hospital with high-risk patients and limited resources.