M Heys

Fall in Haemophilus influenzae serotype b (Hib) disease following implementation of a booster campaign

Objective: To assess the impact of a Hib vaccination booster campaign targeting children aged 6 months to 4 years between May and September 2003, following a nationwide increase in the number of invasive Haemophilus influenzae serotype b (Hib) cases in all age groups after 1999. Design: The Health Protection Agency Centre for Infections prospectively monitors all cases of H influenzae disease in England and Wales and collects data from primary care trusts (PCTs) on coverage for vaccines in the childhood programme. Population: Adults and children in England and Wales (January 1991 to December 2006) Results: Data on vaccine coverage during the Hib booster campaign were available for 288/303 (95%) PCTs in England and revealed coverage of 71.8% for the 6–12-month age group and 63.2% for the 13–48-month age group. The Hib booster campaign resulted in a dramatic reduction in cases within 12 months in the age groups targeted for the booster. This decline was followed by a reduction in the number of cases reported among older children and adults. Since the campaign, however, there has been an increase in the number of cases reported among 1–3-year-old children (13 cases in 2004, 26 cases in 2005 and 32 cases in 2006), primarily in children who were too young to be vaccinated in the booster campaign. This group of children will be targeted in the pre-school catch-up programme that began in September 2007. Conclusions: The Hib booster campaign has helped to re-establish herd immunity in the UK. The increase in Hib disease among toddlers after 2004 supports the decision to introduce routine boosting for Hib at 12 months of age.

What do we really know about infants who attend Accident and Emergency departments

Aims: Accident and Emergency attendances continue to rise. Infants are disproportionately represented. This study examines the clinical reasons infants attend UK Accident and Emergency departments. Methods: A retrospective review of 6,667 infants aged less than one year attending Accident and Emergency at two district general hospitals in London from 1st April 2009 to 30th March 2010. All infants had been assigned to a diagnostic category by the medical coding department according to National Health Service (NHS) data guidelines, based on the clinical diagnoses stated in the medical records. The Accident and Emergency case notes of a random subsample of 10% of infants in each of the top five recorded diagnostic categories (n = 535) were reviewed in detail and audited against the standard national NHS data set. Results: The top 5 clinical diagnoses were ‘infectious diseases’, ‘gastrointestinal’, ‘respiratory’, ‘unclassifiable’ and ‘no abnormality detected’ (NAD). A third of infants were originally given a diagnosis of unclassifiable (21.5%) or NAD (11.5%). After detailed case-note review, we were able to reduce this to 9.7% (95% confidence interval (CI): 9.0, 10.4) and 8.8% (95% CI: 8.1, 9.5), respectively. Conclusion: This study demonstrates the importance of providing a clear clinical diagnosis and coding system for Accident and Emergency attendances and understanding that system fully. This would allow for better informed health service evaluation, planning and research as each of these relies on the interpretation of routine health-care data. Furthermore, the relatively high proportion (10%) of infants attending with no discernible underlying medical abnormality suggests the health needs of a significant proportion of infants attending Accident and Emergency departments may be better addressed by alternative service provision and/or improved education and support to parents.

Understanding parents’ and professionals’ knowledge and awareness of autism in Nepal

Autism is a global phenomenon. Yet, there is a dearth of knowledge of how it is understood and its impact in low-income countries. We examined parents’ and professionals’ understanding of autism in one low-income country, Nepal. We conducted focus groups and semi-structured interviews with parents of autistic and non-autistic children and education and health professionals from urban and rural settings (n = 106), asking questions about typical and atypical development and presenting vignettes of children to prompt discussion. Overall, parents of typically developing children and professionals had little explicit awareness of autism. They did, however, use some distinctive terms to describe children with autism from children with other developmental conditions. Furthermore, most participants felt that environmental factors, including in-utero stressors and birth complications, parenting style and home or school environment were key causes of atypical child development and further called for greater efforts to raise awareness and build community capacity to address autism. This is the first study to show the striking lack of awareness of autism by parents and professionals alike. These results have important implications for future work in Nepal aiming both to estimate the prevalence of autism and to enhance support available for autistic children and their families.

The impact of out-of-hospital models of care on paediatric emergency department presentations

Objective To estimate the potential impact of enhanced primary care and new out-of-hospital models (OOHMs) on emergency department (ED) presentations by children and young people (CYP). Design Observational study. Patients & setting Data collected prospectively on 3020 CYP 0–17.9 years from 6 London EDs during 14 days by 25 supernumerary clinicians. CYP with transient acute illness, exacerbation of long-term condition (LTC), complex LTC/disability and injury/trauma were considered manageable within OOHM. OOHMs assessed included nurse-led services, multispecialty community provider (MCP), primary and acute care system (PACS) plus current and enhanced primary care. Measures Diagnosis, severity; record of investigations, management and outcome that occurred; objective assessment of clinical need and potential alternative management options/destinations. Results Of the patients 95.6% had diagnoses appropriate for OOHM. Most presentations required assessment by a clinician with skills in assessing illness (39.6%) or injuries (30.9%). One thousand two hundred and ninety-one (42.75%) required no investigations and 1007 (33.3%) were provided only with reassurance. Of the presentations 42.2% were judged to have been totally avoidable if the family had had better health education. Of the patients 26.1% were judged appropriate for current primary care (community pharmacy or general practice) with 31.5% appropriate for the combination of enhanced general practice and community pharmacy. Proportions suitable for new models were 14.1% for the nurse-led acute illness team, MCP 25.7%, GP federation CYP service 44.6%, comprehensive walk-in centre for CYP 64.3% and 75.5% for a PACS. Conclusions High proportions of ED presentations by CYP could potentially be managed in new OOHMs or by enhancement of existing primary care.

Prenatal and perinatal risk factors for disability in a rural Nepali birth cohort

Background Improving newborn health remains a global health priority. Little however is known about the neurodevelopmental consequences for survivors of complications in pregnancy, labour and the neonatal period in in low-income countries outside of small selective and typically urban facility studies. We ask which antenatal, birth and neonatal factors are associated with disability in childhood in a large community birth cohort from rural Nepal. Methods 6436 infants were recruited during a cluster randomised control trial (RCT) of participatory womens groups (ISRCTN31137309), of whom 6075 survived beyond 28 days. At mean age of 11∙5 years (range 9.5–13.1), 4219 children (27% lost to follow-up) were available for disability screening which was conducted by face-to-face interview using the Module on Child Functioning and Disability produced by the Washington Group/UNICEF. Hypothesised risk factors for disability underwent multivariable regression modelling. Findings Overall prevalence of disability was 7.4%. Maternal underweight (OR 1.44 (95% CI 1.01–2.08)), maternal cohabitation under 16 years of age (OR 1.50 (1.13–2.00)), standardised infant weight at 1 month (OR 0.82 (0.71–0.95)) and reported infant diarrhoea and vomiting in the first month (OR 2.48 (1.58–3.89)) were significantly associated with disability adjusted for trial allocation. The majority of hypothesised risk factors, including prematurity, were not significant. Interpretation Proxies for early marriage and low birth weight and a measure of maternal undernutrition were associated with increased odds of disability. The lack of association of most other recognised risk factors for adverse outcome and disability may be due to survival bias.

The long-term impact of community mobilisation through participatory women's groups on women's agency in the household: A follow-up study to the Makwanpur trial

Women’s groups practicing participatory learning and action (PLA) in rural areas have been shown to improve maternal and newborn survival in low-income countries, but the pathways from intervention to impact remain unclear. We assessed the long-term impact of a PLA intervention in rural Nepal on women’s agency in the household. In 2014, we conducted a follow-up study to a cluster randomised controlled trial on the impact of PLA women’s groups from 2001–2003. Agency was measured using the Relative Autonomy Index (RAI) and its subdomains. Multi-level regression analyses were performed adjusting for baseline socio-demographic characteristics. We additionally adjusted for potential exposure to subsequent PLA groups based on women’s pregnancy status and conduct of PLA groups in areas of residence. Sensitivity analyses were performed using two alternative measures of agency. We analysed outcomes for 4030 mothers (66% of the cohort) who survived and were recruited to follow-up at mean age 39.6 years. Across a wide range of model specifications, we found no association between exposure to the original PLA intervention with women’s agency in the household approximately 11.5 years later. Subsequent exposure to PLA groups was not associated with greater agency in the household at follow-up, but some specifications found evidence for reduced agency. Household agency may be a prerequisite for actualising the benefits of PLA groups rather than a consequence.

G259(P) A systematic review of health worker-led interventions to reduce mortality in low birth weight neonates in low and middle-income institutional settings

Aim The majority of the 3.3 million annual neonatal deaths worldwide occur because proven and simple interventions dependent upon skilled human resources are not implemented. 60–80% of these deaths occur in low birth weight (LBW) neonates less than 2.5 kg, with 96.5% of the 20 million LBW neonates being born in the developing world. The aim of this research is to carry out the first systematic literature review on health worker-led interventions to reduce mortality in LBW neonates in institutional settings in low and middle-income (LMIC) countries. Methods We conducted a systematic review of studies meeting our inclusion and exclusion criteria until October 2014 (Figure 1). We searched Pubmed/MEDLINE, Popline, and Cochrane databases utilising a combination of the search terms “low birth weight” or “small for gestational age” and “mortality” and “intervention”. We included all studies of health worker led facility-based postnatal interventions in LMIC that assessed the outcome of neonatal mortality in LBW infants. We excluded articles with abstracts not available, articles that were not in English, and research with subjects not human or subjects not infants. Abstract G259(P) Figure 1 Results We identified six studies reporting LBW neonatal mortality outcomes for health worker led interventions or a package of interventions in institutional settings in LMIC (Table 1). We employed the Hierarchy of Evidence framework, which evaluates health care interventions, to rank the strength of research evidence as excellent, good, fair or poor (Table 2). Only one study received an excellent ranking, the systematic review on kangaroo mother care (KMC), which included randomised controlled trials that demonstrated a statistically significant decrease in neonatal mortality rates. Abstract G259(P) Table 1 Summary of studies reviewed Authors Type of study Subjects Country, setting location Objective Interventions Outcomes Agarwal, R. et. al, 2007 Before and after 7938 live births before with 282 infants <1500g and 74 <1000g, 7311 live births after with 262 <1500g and 66 <1000g. India, low resource obstetric teaching hospital To evaluate impact of simple interventions on neonatal mortality. Package included: rational admissions and early discharge, maternal involvement, asepsis routines, enteral feeding, protocol-based management, rational antibiotics and nurse training. NMR declined during the intervention period as compared to control period (20.3 versus 29.3 per 1000 live births; relative risk 0.69, 95% confidence interval (CI) 0.57 to 0.85). Arif & Arif, 1999 Prospective matched case control study 361 LBW (151 case; 211 control) Pakistan, urban hospital To randomize LBW babies to care inside an incubator by nurses or care by mother at bedside Care in an incubator by nurse or care by mother at mother’s bedside Mortality rate decreased by 57% when infant’s were cared for by mothers, p<. 001 Conde-Agudelo, A., Diaz-Rossello, J., 2014 Systematic review- 18 RCT 2571 LBW infants 13 hospitals in LMIC and 5 hospitals in high income countries To ascertain whether or not there is evidence to support the use of KMC in LBW infants instead of conventional care Kangaroo mother care with mother or caregiver Overall, KMC was associated with a statistically significant reduction in the risk of mortality at discharge or 40–41 weeks’ postmenstrual age (3.2% vs 5.3%; typical RR 0.60, 95% CI 0.39 to 0.92) Msemo, G. et. al, 2013 Before and after 1000 LBW infants before and 7,423 LBW after Three major referral hospitals in Tanzania, 4 regional hospitals, 1 district hospital To assess if a new education program to improve delivery room stabilization and resuscitation can decrease early neonatal death in LBW and non LBW infants Helping Babies Breathe-simple interventions to improve delivery room stabilization and resuscitation NMR decreased from 61 per 1,000 live births to 29 per 1,000 live births, RR 0.48; 95% CI 0.35–0.6, P< .0001 Mufti, P., Setna, F. & Nazir, K., 2006 Before and after 2498 LBW babies (971-term, 1527 preterm) Karachi, Pakistan, large teaching hospital To improve newborn care and survival rates of LBW babies through the training of medical and nursing staff Training of medical and nursing staff including neonatal resuscitation The NMR decreased from 22.4 to 12.3 per 1,000 live births. Early NMR was used or death of a live born infant over 500g in the first 7 days of life. Van Der Mei, 1994 Non-controlled descriptive study 567 LBW infants Agogo Hospital, Ashanti region in Ghana To establish the survival rate in the neonatal period with the scale up of neonatal care Simple staff training program and inclusion of mothers in the provision of newborn care The mortality rate was 26.8 per 1,000 live births, the researchers felt this was a favorable outcome with small changes in care provision Abbreviations used: NMR- neonatal mortality rate, LBW- low birth weight, KMC- kangaroo mother care Abstract G259(P) Table 2 Studies ranked against the hierarchy of evidence framework Conclusion The literature review demonstrates the limited evidence on health worker-led facility-based postnatal interventions to decrease mortality in LBW infants. Even where adequate evidence exists for impact of interventions on LBW mortality, for example, KMC, there has yet to be consistent scale-up. Further research is necessary utilising more rigorous methodology to ascertain effectiveness of interventions, as well as to identify cost-effective and sustainable strategies to allow for widespread implementation and dissemination of proven interventions.

Could Postnatal Women’s Groups Be Used to Improve Outcomes for Mothers and Children in High-Income Countries? A Systematic Review

Introduction Participatory postnatal women’s groups have been shown to have a significant impact on maternal and neonatal mortality in low-income countries. However, it is not clear whether this approach can be translated to high-income countries (HICs). We conducted a systematic review to answer the question: “Can postnatal women’s groups improve health outcomes for mothers and children in high-income countries?” Methods MEDLINE, EMBASE and Cochrane databases were searched for randomised controlled trials testing any group-based intervention during the postnatal period, in HICs. No limitations were applied to stated outcomes. Results Nine trials, including 3029 women, fulfilled the criteria. Group-based interventions, facilitated by health professionals, ranged from didactic to participant-led. Three trials addressed postnatal depression, one addressed physical activity, whilst the remainder looked at multiple health or social outcomes. Three trials reported a significant association between their intervention and at least one outcome measure. Study limitations included poor and inequitable intervention uptake, low participant retention, small sample size and incomplete intervention description. Discussion This review found limited and incompletely described evidence testing the use of postnatal group-based interventions to improve health outcomes in HICs. Promising results were reported when the obstacles of sample size and group attendance were overcome. Studies reporting positive impacts on primary outcomes reported higher attendance rates and involved a psychoeducational or cognitive behavioural component in their group approaches. Further research should design and evaluate implementation strategies, assess the use of lay support workers in community settings to improve attendance and retention, and examine the effect of the group environment on outcomes.

G266(P) Adolescent cohorts assessing growth, cardiovascular and cognitive outcomes in low and middle-income countries

Life-course studies are needed to explore how exposures during adolescence, particularly puberty, contribute to later cardiovascular risk and cognitive health in low and middle-income countries (LMIC), where 90% of the world’s young people live. The extent of any existing cohorts investigating these outcomes in LMIC has not previously been described. Methods We performed a systematic literature review to identify population cohort studies of adolescents in LMIC that assessed anthropometry and any of cardiovascular risk (blood pressure, physical activity, plasma glucose/lipid profile and substance misuse), puberty (age at menarche, Tanner staging, or other form of pubertal staging) or cognitive outcomes. Studies that recruited participants on the basis of a pre-existing condition or involved less than 500 young people were excluded. Findings 1829 studies were identified, and 24 cohorts fulfilled inclusion criteria based in Asia (10), Africa (6) and South/Central America (8). 14 (58%) of cohorts identified were based in one of four countries; India, Brazil, Vietnam or Ethiopia. Only 2 cohorts included a comprehensive cardiovascular assessment, tanner pubertal staging, and cognitive outcomes. Conclusion Improved utilisation of existing datasets and additional cohort studies of adolescents in LMIC that collect contemporaneous measures of growth, cognition, cardiovascular risk and pubertal development are needed to better understand how this period of the life course influences future non-communicable disease morbidity and cognitive outcomes.

Evaluation of ‘TRY’: an algorithm for neonatal continuous positive airways pressure in low-income settings

Background Non-invasive respiratory support using bubble continuous positive airway pressure (bCPAP) is useful in treating babies with respiratory distress syndrome. Despite its proven clinical and cost-effectiveness, implementation is hampered by the inappropriate administration of bCPAP in low-resource settings. A clinical algorithm—‘TRY’ (based on Tone: good; Respiratory distress; Yes, heart rate above 100 beats/min)—has been developed to correctly identify which newborns would benefit most from bCPAP in a teaching hospital in Malawi. Objective To evaluate the reliability, sensitivity and specificity of TRY when employed by nurses in a Malawian district hospital. Methods Nursing staff in a Malawian district hospital baby unit were asked, over a 2-month period, to complete TRY assessments for every newly admitted baby with the following inclusion criteria: clinical evidence of respiratory distress and/or birth weight less than 1.3 kg. A visiting paediatrician, blinded to nurses’ assessments, concurrently assessed each baby, providing both a TRY assessment and a clinical decision regarding the need for CPAP administration. Inter-rater reliability was calculated comparing nursing and paediatrician TRY assessment outcomes. Sensitivity and specificity were estimated comparing nurse TRY assessments against the paediatrician’s clinical decision. Results Two hundred and eighty-seven infants were admitted during the study period; 145 (51%) of these met the inclusion criteria, and of these 57 (39%) received joint assessments. The inter-rater reliability was high (kappa 0.822). Sensitivity and specificity were 92% and 96%, respectively. Conclusions District hospital nurses, using the TRY-CPAP algorithm, reliably identified babies that might benefit from bCPAP and thus improved its effective implementation.