Philippe Donnen

Community-acquired bacteremia among hospitalized children in rural central Africa.

OBJECTIVE To describe the epidemiology of community-acquired bacteremia in children admitted to a rural hospital in central Africa and to identify useful diagnostic signs or symptoms. METHODS On admission, a blood culture was obtained from all children admitted to Childrens Hospital of Lwiro between 1989 and 1990. Clinical and biologic signs of infection and nutritional status were recorded. RESULTS Among the 779 children included in the study, 15.9% were bacteremic on admission. The rate of bacteremia was the highest among children with jaundice (20/56; 35.7%) and fever (119/487; 24.4%). In contrast, children with severe malnutrition had a lower rate of bacteremia (13.2%) than weight growth retarded or well-nourished children (19.5%) (P = 0.046). Fever was the most useful diagnostic criteria (sensitivity and negative predictive value of 96.0% and 97.8%, respectively) even in severely malnourished children (sensitivity and negative predictive value of 96.4% and 99.1%, respectively). Enterobacteriacea, mostly Salmonella spp, caused 73% of the bacteremia. There was a high rate of resistance to ampicillin and chloramphenicol among the responsible organisms. Only 31 (47.7%) of 65 bacteremic children responded to the combination of ampicillin and gentamicin. The presence of bacteremia on admission did not significantly increase the risk of morality during hospitalization (19.4% compared with 13.5%; P = 0.088). Age less than 12 months and jaundice were independent risk factors for deaths in bacteremic children. CONCLUSIONS Community-acquired bacteremia caused by multiresistant Enterobacteriacea is an important problem of hospitalized well-nourished and malnourished children in central Africa. Fever on admission is a sensitive diagnostic sign, even in malnourished children.

Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo – A Case study of Lubumbashi City

BackgroundThe use of maternal health services, known as an indirect indicator of perinatal death, is still unknown in Lubumbashi. The present study was therefore undertaken in order to determine the factors that influence the use of mother and child healthcare services in Lubumbashi, Democratic Republic of the Congo.MethodsThis was transversal study of women residing in Lubumbashi who had delivered between January and December 2009. In total, 1762 women were sampled from households using indicator cluster surveys in all health zones. Antenatal consultations (ANC), delivery assisted by qualified healthcare personnel (and delivery in a healthcare facility) as well as postnatal consultations (PNC) were dependent variables of study. The factors determining non-use of maternal healthcare services were researched via logistic regression with a 5% materiality threshold.ResultsThe use of maternal healthcare services was variable; 92.6% of women had attended ANC at least once, 93.8% of women had delivered at a healthcare facility, 97.2% had delivered in the presence of qualified healthcare personnel, while the rate of caesarean section was 4.5%. Only 34.6% postnatal women had attended PNC by 42 days after delivery. During these ANC visits, only 60.6% received at least one dose of vaccine, while 38.1% received Mebendazole, 35.6% iron, 32.7% at least one dose of SulfadoxinePyrimethamine, 29.2% folic acid, 15.5% screening for HIV and 12.8% an insecticide treated net.In comparison to women that had had two or three deliveries before, primiparous and grand multiparous women were twice as likely not to use ANC during their pregnancy. Women who had unplanned pregnancies were also more likely not to use ANC or PNC than those who had planned pregnancies alone or with their partner. The women who had not used ANC were also more likely not to use PNC. The women who had had a trouble-free delivery were more likely not to use PNC than those who had complications when delivering.ConclusionIn Lubumbashi, a significant proportion of women continue not to make use of healthcare services during pregnancy, as well as during and after childbirth. Women giving birth for the first time, those who have already given birth many times, and women with an unwanted pregnancy, made less use of ANC. Moreover, women who had not gone for ANC rarely came back for postnatal consultations, even if they had given birth at a healthcare facility. Similarly, those who gave birth without complications, less frequently made use of postnatal consultations. As with ANCs, women with unwanted pregnancies rarely went for postnatal visits.In addition to measures aimed at reinforcing women’s autonomy, efforts are also needed to reinforce and improve the information given to women of childbearing age, as well as communication between the healthcare system and the community, and participation from the community, since this will contribute to raising awareness of safe motherhood and the use of such services, including family planning.

Improvements in nutritional management as a determinant of reduced mortality from community-acquired lower respiratory tract infection in hospitalized children from rural central Africa.

Background: In-hospital mortality from lower respiratory tract infections (LTRI) is unacceptably high in developing countries where LTRI are still a leading cause of death. Objective: To identify new approaches to reduce in-hospital mortality of LRTI through the improvement of its management. Methods: The prospectively collected database of children admitted during an 11-year period with LRTI in a pediatric rural hospital in Central Africa was reviewed to determine the predictors of death and to evaluate the impact on mortality of 4 different protocols for the management of malnutrition. Results: During the study period, 859 children were admitted with a nonmeasles severe LRTI. In the 3-year period during which blood cultures were obtained, 29.0% of the children with LRTI were bacteremic, and multiresistant Enterobacteriaceae were recovered in 81.4% of positive blood cultures. Independent predictors of death in children without edema were age <24 months, dehydration and hepatomegaly with adjusted odds ratios (numbers in parentheses, 95% confidence interval) of 3.47 (1.70–7.08), 4.24 (2.11–8.50) and 2.90 (1.43–5.85), respectively. In those with edema, a significantly increased risk of death was noted for girls [4.31 (1.71–10.90)], in children with z-score of weight to height ≤ −3 [5.45 (1.67–17.79)] and when the serum albumin was <16 g/l [2.58 (1.01–6.58)]. The improvement in the management of malnutrition was followed by a reduction of LRTI-related mortality in children with edema from 32.4 to 8.9% (P < 0.001). In children without edema, the LRTI-related mortality decreased from ~12% to 3.5% when their diet was supplemented with micronutrients. Conclusion: This study indicates that the improvement of the management of underlying nutritional deficiencies is crucial for the reduction of the high in-hospital case fatality rate associated with severe nonmeasles LRTI. The empiric antibiotic regimen should be modified to cover for multiresistant Enterobacteriaceae.

Effect of daily low dose of vitamin A compared with single high dose on morbidity and mortality of hospitalized mainly malnourished children in senegal: a randomized controlled clinical trial.

Background:In vitamin A-deficient populations, children hospitalized with infections and/or malnutrition are at particular risk of developing severe vitamin A (VA) deficiency. High-dose VA supplements are recommended as part of the treatment but results on its effect on recovery from morbidity and on prevention from nosocomial morbidity are conflicting.Objective:We aimed to assess the effect of a single high dose and daily low dose of VA on hospitalized malnourished childrens morbidity.Design:We carried out a double-blind, randomized trial in 604 and 610 Senegalese hospitalized children. The first mentioned batch received a high-dose VA supplement (200 000 IU) on admission, the second a daily low-dose VA supplement (5000 IU per day) during hospitalization. Children were followed up until discharged. Data on all-cause morbidity were collected daily.Results:Survival analysis showed that the incidence of respiratory disease was significantly lower in the low-dose group than in the high-dose group, hazard ratios (HR): 0.26, 95% CI: 0.07–0.92. The duration of respiratory infection was also significantly lower in the low-dose group than in the high-dose group (HR of cure: 1.41, 95% CI: 1.05–1.89). Duration and incidence of diarrhoea were not significantly different between treatment groups. In children with oedema on admission, mortality was significantly lower in the low-dose group (Adjusted odds ratio: 0.21; 95% CI: 0.05–0.99).Conclusions:Daily low dose of VA compared with single high dose significantly reduced duration and incidence of respiratory infection but not of diarrhoea in hospitalized children.

Randomized controlled trial of the effectiveness of a soybean-maize-sorghum-based ready-to-use complementary food paste on infant growth in South Kivu Democratic Republic of Congo.

BACKGROUND Evidence of the effectiveness of lipid-based ready-to-use complementary foods (RUCF) at improving linear growth among infants aged 6-12 mo is scarce, and further work is warranted. OBJECTIVE The objective was to assess the effectiveness of a fortified soybean-maize-sorghum RUCF paste compared with a fortified corn soy blend (UNIMIX) porridge on the prevalence of underweight and stunting among infants in South Kivu Province, Democratic Republic of Congo. DESIGN Infants were randomly assigned at 6 mo of age to receive either RUCF (n = 691) or UNIMIX (n = 692) for 6 mo. In addition to admission and monthly anthropometric measurements, hemoglobin, triglyceride, and cholesterol were measured at enrollment and at the end of the study. RESULTS No significant differences in the prevalence of stunting (RUCF: 48.6%; UNIMIX: 46.4%; P = 0.31), the prevalence of underweight (RUCF: 20.4%; UNIMIX: 18.2%; P = 0.42), or weight gain (RUCF: 1.2 ± 0.7 kg; UNIMIX: 1.3 ± 0.7 kg; P = 0.08) were found. A small but statistically significant difference in length gain (RUCF: 5.2 ± 2.0; UNIMIX: 5.4 ± 2.0; P = 0.03) was found. No significant differences in the concentrations of hemoglobin, serum triglyceride, and serum cholesterol were found between the 2 groups. CONCLUSION No significant differences were found between the RUCF and UNIMIX in the reduction of the prevalence of stunting and underweight at 12 mo of age among rural Congolese infants. This trial was registered at controlled-trials.com as ISRCTN20267635.

Effect of iron or multiple micronutrient supplements on the prevalence of anaemia among anaemic young children of a malaria-endemic area: a randomized double-blind trial

Objective  To assess the effect of supplementation with iron or multiple micronutrients (MM) on the prevalence of anaemia in a malaria‐endemic area.

Iodine and iron status of pregnant women in Lubumbashi, Democratic Republic of Congo.

OBJECTIVE Adequate iodine and Fe intakes are imperative during pregnancy to prevent fetal defects, but such data are not available in the Democratic Republic of Congo. We aimed to assess iodine and Fe status in pregnant women from Lubumbashi. DESIGN Cross-sectional study. We measured urinary iodine concentration (UIC) in random urine samples using a modified Sandell–Kolthoff digestion method; the WHO reference medians were used to classify iodine intake as deficient, adequate, more than adequate or excessive. Serum ferritin concentrations were measured by immunoenzymatic assay and considered insufficient when ,12 ng/ml. SETTING Maternity units from rural, semi-urban and urban areas of Lubumbashi, Democratic Republic of Congo. SUBJECTS Two hundred and twenty-five randomly selected pregnant women attending prenatal consultation, seventy-five postpartum women and seventy-five non-pregnant women as controls. RESULTS Overall median UIC in pregnant women was 138 (interquartile range: 105–172) mg/l, indicating iodine deficiency, whereas postpartum and nonpregnant women had adequate iodine intake: median UIC5144mg/l and 204mg/l,respectively. Median UIC values were lower in late pregnancy than in early pregnancy: in the first, second and third trimester respectively 255mg/l, 70mg/l and 88mg/l in the rural area; 306mg/l, 166mg/l and 68mg/l in the semi-urban area; and 203mg/l, 174mg/l and 99mg/l in the urban area. Fe was insufficient in 39% of pregnant women compared with 21% of non-pregnant and postpartum women. In the third trimester, deficiencies in both iodine and Fe were high: 40%, 12% and 18% in the rural, semi-urban and urban areas, respectively. CONCLUSIONS Our data suggest that pregnant women are at risk of iodine and Fe deficiencies in Lubumbashi. Country policies fighting against iodine and Fe deficiencies during pregnancy should be reinforced.

Effect of an improved local ingredient-based complementary food fortified or not with iron and selected multiple micronutrients on Hb concentration

OBJECTIVE To assess the effect of an improved local ingredient-based gruel fortified or not with selected multiple micronutrients (MM) on Hb concentration of young children. DESIGN In a nutrition centre that we opened in their villages, children received either MM supplement (containing iron, zinc, vitamin A, vitamin C and iodine) with the improved gruel (MMGG) or the improved gruel only (GG), twice daily, 6 d/week, for 6 months. We assessed baseline and endpoint Hb concentration and anthropometric indices. SETTING Kongoussi, a rural and poor district of Burkina Faso. SUBJECTS In a community-based trial, we randomly assigned 131 children aged 6-23 months with Hb concentrations in the range of 80-109 g/l into two groups. RESULTS The groups did not differ significantly at baseline. Mean baseline Hb concentration was 89·2 (sd 6·5) g/l and 90·3 (sd 8·4) g/l in the GG and the MMGG, respectively (P = 0·42). It increased to 104·1 (sd 11·4) g/l in the GG (P < 0·001) and 107·6 (sd 14·7) g/l in the MMGG (P < 0·001). The between-group difference of 3·5 (95 % CI -1·0, 8·1) g/l in mean (sd) endpoint Hb concentration was not significant (P = 0·13). The endpoint anthropometric indices were not different between the groups. CONCLUSIONS This MM supplement had no additional effect on Hb concentration. Thorough studies are needed to evaluate the actual efficacy of the gruel before its introduction into household routine.

Relapses from acute malnutrition and related factors in a community‐based management programme in Burkina Faso

Community-based management of acute malnutrition (CMAM) is effective in treating acute malnutrition. However, post-discharge follow-up often lacks. We aimed at assessing the relapse rate and the associated factors in a CMAM programme in Burkina Faso. Discharged children from the community nutrition centre were requested to return at least every 3 months for follow-up. The data of recovered children (weight-for-height z-score ≥-2) who were discharged between July 2010 and June 2011 were collected in 45 villages, randomly selected out of 210 in January 2012. Sociodemographic data, economic variables, information on household food availability and the childs food consumption in the last 24 h were collected from the parents. A multivariate Cox proportional hazards regression was used to identify the factors associated to relapse. Of the 637 children, 14 (2.2%) died and 218 (34.2%) were lost to follow-up. The relapse rate [95% confidence interval] among the children who returned for follow-up was 15.4 [11.8-19.0] per 100 children-years. The associated factors to relapses in multivariate Cox regression model were mid-upper arm circumference (MUAC) at discharge below 125 mm, no oil/fat consumption during the last 24 h and incomplete vaccination. To limit relapses, CMAM programmes should avoid premature discharge before a MUAC of at least 125 mm. Nutrition education should emphasize fat/oil as inexpensive energy source for children. Promoting immunization is essential to promote child growth. Periodic monitoring of discharged children should be organized to detect earlier those who are at risk of relapse. The relapse rate should be a CMAM effectiveness indicator.

Sustainability and Scaling-Up Analysis of Community-Based Management of Acute Malnutrition: Lessons Learned from Burkina Faso:

Background Community-based management of acute malnutrition (CMAM) is an effective strategy frequently implemented by nongovernmental organizations, but handing CMAM over to national health systems and scaling it up remains a great challenge. Objective To highlight the challenges to sustainability and scalability of a CMAM program in Burkina Faso. Methods We conducted a review of program reports to evaluate program performance and conducted individual interviews with key informants (health system fieldworkers and officials and program staff members) and focus group discussions with beneficiaries (mothers whose children were attending the program, community volunteers, and village leaders) to analyze the required conditions for scaling up using ExpandNet recommendations. Results The program coverage rate was 90% among children under 5 years of age in the 180 intervention villages. Between June 2007 and December 2010, 19,009 cases of acute malnutrition (AM) among children under 5 years of age were treated, of which 4,308 (22.7%) were cases of severe acute malnutrition (SAM). The recovery rate was 89.4% for moderate acute malnutrition (MAM) and 86.5% for SAM. The case-fatality rate was 2.8% for MAM and 4.2% for SAM. The default rate was 7% for all cases. The prevalence of SAM decreased between 2008 and 2009 from 5.4% to 1.8%. Barriers to sustainability and scaling up were underlined: management by external personnel from the health system, no financial support for the scaling-up process, insufficient national advocacy, and nonsustainable activities (e.g., free care). Conclusions The CMAM program was effective, but the handover conditions and scaling-up requirements were unsatisfactory. We identified poor integration into the health system, lack of resources, and insufficient advocacy.