Julian Kelly

Reduction in Rotavirus-associated Acute Gastroenteritis Following Introduction of Rotavirus Vaccine Into Australia's National Childhood Vaccine Schedule

Introduction: Rotavirus vaccines were introduced into the funded Australian National Immunization Program (NIP) in July 2007. Due to purchasing arrangements, individual states and territories chose either a 2-dose RV1 (Rotarix, GSK) regimen or 3-dose RV5 (Rotateq, Merck/CSL) regimen. This allowed comparison of both vaccines in similar populations with high infant vaccination coverage. Methods: Admission and rotavirus identification data from the major pediatric hospitals in 3 states (2 using RV5, 1 RV1), together with state-based hospitalization and vaccination data from Queensland (RV5) were analyzed for the years before, and up to 30 months following rotavirus vaccine introduction. Emergency encounters and short-stay unit admissions for gastroenteritis are also described. Results: Rotavirus vaccine coverage in Australia is high, with 87% of infants receiving at least 1 dose. Hospital admissions for both rotavirus gastroenteritis and nonrotavirus-coded gastroenteritis were reduced following vaccine introduction in all states, not only for the age group eligible for NIP rotavirus vaccination, but also for children born prior. RV5 vaccine efficacy in Queensland has been estimated at 89.3%. Marked reductions in acute gastroenteritis emergency presentations and short-stay unit admissions have also been observed. Conclusions: Early evidence from the NIP in Australia has demonstrated high rotavirus coverage with both RV1 and RV5. The introduction of both vaccines has been associated with a marked reduction in gastroenteritis admissions, supportive of both direct vaccine protection, as well as with indirect herd protection.

Community-acquired neonatal and infant sepsis in developing countries: efficacy of WHO's currently recommended antibiotics—systematic review and meta-analysis

Objective To review the aetiology and antibiotic resistance patterns of community-acquired sepsis in developing countries in infants where no clear focus of infection is clinically identified. To estimate the likely efficacy of WHOs recommended treatment for infant sepsis. Design A systematic review of the literature describing the aetiology of community-acquired neonatal and infant sepsis in developing countries. Using meta-analytical methods, susceptibility was determined to the antibiotic combinations recommended by WHO: (1) benzylpenicillin/ampicillin and gentamicin, (2) chloramphenicol and benzylpenicillin, and (3) third-generation cephalosporins. Results 19 studies were identified from 13 countries, with over 4000 blood culture isolates. Among neonates, Staphylococcus aureus, Klebsiella spp. and Escherichia coli accounted for 55% (39–70%) of culture positive sepsis on weighted prevalence. In infants outside the neonatal period, the most prevalent pathogens were S aureus, E coli, Klebsiella spp., Streptococcus pneumoniae and Salmonella spp., which accounted for 59% (26–92%) of culture positive sepsis. For neonates, penicillin/gentamicin had comparable in vitro coverage to third-generation cephalosporins (57% vs 56%). In older infants (1–12 months), in vitro susceptibility to penicillin/gentamicin, chloramphenicol/penicillin and third-generation cephalosporins was 63%, 47% and 64%, respectively. Conclusions The high rate of community-acquired resistant sepsis—especially that caused by Klebsiella spp. and S aureus—is a serious global public health concern. In vitro susceptibility data suggest that third-generation cephalosporins are not more effective in treating sepsis than the currently recommended antibiotics, benzylpenicillin and gentamicin; however, with either regimen a significant proportion of bacteraemia is not covered. Revised recommendations for effective second-line antibiotics in neonatal and infant sepsis in developing countries are urgently needed.

Postoperative sleep disturbance in pediatric patients using patient-controlled devices (PCA).

Background : Sleep disturbance has not been well quantified in pediatric postoperative management, yet has broad implications in pain management as well as upon the physical and psychological well‐being of the young patient admitted for surgery. We aimed to describe sleep disturbance in this population using patient‐controlled analgesia (PCA) and then identify the predictors of disturbed sleep.

Global use of the WHO Pocket Book of Hospital Care for Children

Abstract Background: Studies in the last decade have identified major deficiencies in the care of seriously ill children in hospitals in developing countries. Effective implementation of clinical guidelines is an important strategy for improving quality of care. In 2005 the World Health Organization produced the Pocket Book of Hospital Care for Children — Guidelines for Management of Common Childhood Illnesses in Rural and District Hospitals with Limited Resources. Objective: To determine the worldwide distribution, uptake and use of the WHO Pocket Book of Hospital Care for Children. Methods: A systematic online and postal survey was conducted to assess coverage and uptake of the Pocket Book in low- and middle-income countries (LMICs). More than 1000 key stakeholders with varied roles and responsibilities for child health in 194 countries were invited to participate. Indicators used to measure implementation of the guidelines included local adaptation, use as standard treatment and incorporation into undergraduate and postgraduate training. Results: Information was gathered from 354 respondents representing 134 countries; these included 98 LMICs and 50 countries with under-5 childhood mortality rates >40 deaths/1000 live births. Sixty-four LMICs (44% of 145 LMICs worldwide) including 42 high-mortality countries (66% of 64 high-mortality countries worldwide) reported at least partial implementation of the Pocket Book. However, uptake remains fragmented within countries. Conclusion: More than half of all LMICs with high rates of child mortality have reported use and substantial implementation activities, a considerable achievement given minimal resources available for implementation. Improving the accessibility of the Pocket Book and its implementation tools to health workers, and developing a strategic approach to implementation in each country could improve quality of hospital care for children and support efforts towards achieving the Millennium Development Goal 4 targets.

Hospital services for children in the Solomon Islands: Rebuilding after the civil conflict

Aims:  The Solomon Islands health service, infrastructure and economy were severely affected by the civil conflict that occurred between 1998 and 2003. In 2002 plans to rebuild health services for children, especially those provided in provincial hospitals, were developed by paediatricians, in collaboration with the World Health Organization. We aimed to inform this process by an assessment of the strengths and weaknesses of the child health service, particularly in provincial hospitals.

Accessing and Understanding the Evidence

WHO regularly gathers, evaluates, and cites evidence to support its recommendations. How this is done varies between departments, but highly centralized processes, complex methods and expert consultations are often used. WHO guidelines are distributed to health workers and policy-makers in developing countries, but few of these people have the opportunity to be involved in the process of choosing and weighing the evidence to formulate the guidelines that are ostensibly designed for their use. Such incomplete engagement may impede ownership of WHO recommendations, and thus be an obstacle to full implementation. In 2005 WHO published the Pocketbook of Hospital Care for Children, (1) a comprehensive clinical resource for nurses and doctors in developing countries. The Pocketbook contains recommendations on the management of all common conditions, including serious infections, malnutrition, neonatal and surgical problems, injuries, burns and poisoning. These guidelines are an extension of the Integrated Management of Childhood Illness (IMCI) to the first-referral hospital, providing consistency across all levels of health care systems. The Pocketbook aims to address many of the deficiencies in quality and safety of hospital care for children identified in recent years. (2-4) However, the mere production of high-quality guidelines will not ensure implementation, or be sufficient to improve quality of care. A comprehensive approach to the implementation of the WHO Pocketbook includes training strategies and quality assessment tools. Another key component is a process of documenting, updating and disseminating evidence which engages doctors, medical students and nurses in countries throughout the world, This process and the evidence it is collecting are described at the International Child Health Review Collaboration (ICHRC) web site: www.ichrc.org. ICHRC uses Pubmed, a database which references over 4800 journals, including publications from the Cochrane Collaboration. Pubmed is free online and has validated search filters that provide about 95% sensitivity and specificity when compared with the most comprehensive search strategies, involving multiple (often costly) databases and hand-searching of the literature. (5) Reviews given priority in this project are those addressing issues that are critical to the implementation of the guidelines, such as recommendations which challenge common practices in some countries. A reviewers toolkit is available on the web site, and support for reviewers is provided by project coordinators. Standardized search strings are developed with the assistance of a librarian. Drafts are written by primary reviewers, further reviewed by an acknowledged expert in the field, and edited before posting on the web site. The ICHRC process is similar to that used by the Cochrane Collaboration, but there are some important differences. ICHRC has a focus that is broader than therapeutic questions (including diagnosis, etiology and implementation); search strategies prioritize randomized trials, but include other research designs when these are more appropriate. …

Changes in the epidemiology of gastroenteritis in a paediatric short stay unit following the introduction of rotavirus immunisation

Acute gastroenteritis (AGE) has been a significant component of the clinical load in the short stay unit (SSU) at the Royal Childrens Hospital (RCH) since its establishment in 2004. Since the introduction of routine rotavirus immunisation in Australia in 2007 there has been a clinical impression of a substantial reduction in AGE managed in the SSU. This study aimed to examine changes in the epidemiology of AGE in the SSU, and RCH overall, between 2005 and 2009 and explore whether this reflects a change specifically in AGE due to rotavirus.

Profuse watery diarrhoea: An unusual presenting feature of streptococcal toxic shock syndrome

The Lancefield group A β-hemolytic Streptococcus (GAS), also known as Streptococcus pyogenes, causes a spectrum of disease syndromes with varying clinical severity. This ranges from pharyngitis and superficial skin infection to invasive infections. In children, invasive infections can be due to soft tissue infection, pneumonia, osteoarticular infection or bacteremia without focus among others and may be complicated by streptococcal toxic shock syndrome (TSS) in up to one-third of cases. The diagnosis of streptococcal TSS consists of isolation of streptococci from a normally sterile site and hypotension, together with two or more findings of renal or liver dysfunction, coagulopathy, acute respiratory distress syndrome, rash or soft tissue necrosis. This occurs as a result of streptoccocal exotoxins acting as superantigens, which induce the release of large amounts of inflammatory cytokines, leading to capillary leak and tissue damage. Group C and G streptococci have also been associated with TSS. We report the case of a child with invasive GAS disease whose most striking presenting feature was profuse watery diarrhoea.

Profuse watery diarrhoea: an unusual presenting feature of group: A streptococcal toxic shock syndrome in a child

The Lancefield group A β-hemolytic Streptococcus (GAS), also known as Streptococcus pyogenes, causes a spectrum of disease syndromes with varying clinical severity. This ranges from pharyngitis and superficial skin infection to invasive infections. In children, invasive infections can be due to soft tissue infection, pneumonia, osteoarticular infection or bacteremia without focus among others and may be complicated by streptococcal toxic shock syndrome (TSS) in up to one-third of cases. The diagnosis of streptococcal TSS consists of isolation of streptococci from a normally sterile site and hypotension, together with two or more findings of renal or liver dysfunction, coagulopathy, acute respiratory distress syndrome, rash or soft tissue necrosis. This occurs as a result of streptoccocal exotoxins acting as superantigens, which induce the release of large amounts of inflammatory cytokines, leading to capillary leak and tissue damage. Group C and G streptococci have also been associated with TSS. We report the case of a child with invasive GAS disease whose most striking presenting feature was profuse watery diarrhoea.

Profuse watery diarrhoea: An unusual presenting feature of streptococcal toxic shock syndrome: Diarrhoea and streptococcal toxic shock

The Lancefield group A β-hemolytic Streptococcus (GAS), also known as Streptococcus pyogenes, causes a spectrum of disease syndromes with varying clinical severity. This ranges from pharyngitis and superficial skin infection to invasive infections. In children, invasive infections can be due to soft tissue infection, pneumonia, osteoarticular infection or bacteremia without focus among others and may be complicated by streptococcal toxic shock syndrome (TSS) in up to one-third of cases. The diagnosis of streptococcal TSS consists of isolation of streptococci from a normally sterile site and hypotension, together with two or more findings of renal or liver dysfunction, coagulopathy, acute respiratory distress syndrome, rash or soft tissue necrosis. This occurs as a result of streptoccocal exotoxins acting as superantigens, which induce the release of large amounts of inflammatory cytokines, leading to capillary leak and tissue damage. Group C and G streptococci have also been associated with TSS. We report the case of a child with invasive GAS disease whose most striking presenting feature was profuse watery diarrhoea.