[health-vn] Abstracts of presentations to be given at the ICHG meeting, 1st April 2009, York, UK

[Vern Weitzel]

meeting, 1st April 2009, York, UK
Date: Mon, 30 Mar 2009 11:33:37 -0700
From: Arlene Cohen <arlenegcohen at gmail.com>
To: Pac. Reg. Med. Dist. List <arlenegcohen at gmail.com>
References: <82936816-5bdb-4c39-838a-b936bfb0b5b4 at dgroups.org>

FYI
---------- Forwarded message ----------
From: Neil Pakenham-Walsh <neil.pakenham-walsh at ghi-net.org>
Date: Mon, Mar 30, 2009 at 11:23 AM
Subject: [CHILD2015] Abstracts of presentations to be given at the
ICHG meeting,    1st April 2009, York, UK
To: Child Healthcare Information and Learning Discussion-group 2015
<CHILD2015 at dgroups.org>


Dear CHILD2015 colleagues,

The leading paediatrics journal, Archives of Disease in Childhood,
today published abstracts of six of the presentations that will be
given at the International Child Health Group meeting this Wednesday
1st April, in York, UK. I attach the abstracts below.

Several of the authors are CHILD2015 members. If any of the topics
below are of interest to you and you would like to make comments or
ask questions, please send a message to child2015 at dgroups.org

Also, three of the four members of the CHILD2015 moderation team
(myself, Steve Allen and Ed Cooper) will be present at the meeting. If
you would like us to put any comments or questions to the speakers on
your behalf, please let us know. After the meeting we shall send a
summary of the event to CHILD2015.

Best wishes,
Neil

Neil Pakenham-Walsh
Lead moderator, CHILD2015

ABSTRACTS: Archives of Disease in Childhood 2009;94(Supplement 1):A49-A51

DISEASE BURDEN AND RISK-BENEFIT IMPLICATIONS OF USING NEW WHO CHILD
GROWTH STANDARDS TO DIAGNOSE SEVERE ACUTE MALNUTRITION IN INFANTS LESS
THAN 6 MONTHS OF AGE: SECONDARY DATA ANALYSIS OF 21 DEVELOPING COUNTRY
DEMOGRAPHIC AND HEALTH SURVEYS

1H. Blencowe, 2M. Kerac, 3M. McGrath, 2C. Grijalva-Eternod, 2A. Seal.
1London School of Hygiene and Tropical Medicine, London, UK, 2UCL
Centre for International Health and Development, London, UK,
3Emergency Nutrition Network, Oxford, UK

Background: Using established diagnostic criteria together with new
World Health Organization child growth standards (WHO-GS) categorises
more children aged 6-59 months with severe acute malnutrition (SAM).
General consensus is that this may be beneficial: more children become
eligible for evidence-based therapeutic feeding. To date, the effects
of WHO-GS on SAM in infants aged less than 6 months have not been
examined. This is an important research gap: there are already
difficulties and challenges managing SAM in this age group. In this
study, we describe how WHO-GS affect burden-of-disease estimates in
infants. This is essential information for planning child nutrition
and health services.

Methods: We analysed secondary data from recent demographic and health
surveys from 21 developing countries. The prevalence of SAM
(weight-for-height <-3Z) was calculated using both National Center for
Health Statistics (NCHS) growth references and WHO-GS.

Results: Data for 163 230 children (15 537 aged <6 months; 147 695
aged 6-59 months) were examined. Diagnosing SAM with the new WHO-GS
rather than the old NCHS reference increases the prevalence of infant
(<6 months) SAM markedly: odds ratio (OR) 5.5 (95% CI 4.81 to 6.32).
There are smaller but still significant increases in SAM in children
aged 6-59 months: OR 1.8 (95% CI 1.73 to 1.90).

Conclusions: Increases in SAM are considerably greater in infants aged
less than 6 months than in those aged 6-59 months. Policy makers
rolling out the new WHO-GS need to consider possible adverse
risk-benefit implications. The benefits of labelling more infants with
SAM might be marginal: the evidence base for treatment of SAM in
infants is weak; skilled breastfeeding support is scarce; inpatient
treatment cannot be easily scaled up. Risks are potentially serious:
concerned carers may inappropriately introduce "top-up" foods or
breast-milk substitutes, thus undermining exclusive breastfeeding
(which is known to influence mortality). To address these concerns,
WHO-GS implementation could be delayed until clearer risk-benefit
evidence emerges or separate SAM diagnostic criteria for infants less
than 6 months could be considered.


FAMILY SIZE AND USE OF CONTRACEPTION IN GULU, NORTHERN UGANDA
B. Cheesebrough. Gulu University, Gulu, Uganda

Introduction: Gulu Referral Hospital is the main government hospital
in the economic capital of Northern Uganda. Gulu district has been the
location of insurgent fighting by the Lord's Resistance Army from 1987
to 2006 and there has been much family disruption during this period
as a result of the breakdown of the healthcare system, child
kidnapping and other effects of war. There are now approximately 700
000 people living in internally displaced persons camps.

Aims: To assess family size and the use of contraception in families
of children admitted to Gulu Referral Hospital.

Methods: Mothers of children admitted to the paediatric ward over a
2-week period (50 in total) were asked to complete a verbal
questionnaire. The questions were posed by the attending doctor and
translated to Acholi by the attending nurse. No mothers declined the
questionnaire but five children were excluded as they were accompanied
by an adult other than their mother.

Results: The mean number of biological children including the index
child was 3.7 (range 1-9). In addition, 62% families had adopted at
least one child and 34% had adopted two or more children. 46% of
children adopted were children of siblings and 19% were children of
"co-wives". 56% of respondents wanted no more children (mean number of
children 4.9) and 40% of respondents wanted to extend their family. Of
those who wanted more children, the most desired number of children
was four (55%) or five (20%). Of those who wanted no more children,
43% were using contraception and 57% were not. Overall, 40% of
respondents were using contraception, with 75% of those using depot
injections and 15% the oral contraceptive pill. Of those who were not
using contraception, 70% said they would like to have information
about contraception and 52% were unable to name any contraceptive
method. 63% cited lack of information as the main reason why they were
not using contraception, 13% cited fear of side effects and 13%
husband's preference.

Conclusions: In Gulu, women generally aim to have four or five
children but more than half are also accommodating at least one
adopted child, usually an orphaned child of a close relative. Less
than half of the women who want no more children are using
contraception, and knowledge about methods of contraception is poor.
The most commonly used and most commonly named method of contraception
is depot injections.


FREQUENCY OF PRESENTATION TO HEALTHCARE WORKERS AND OTHER
PROFESSIONALS IN NORTHERN UGANDA

B. Cheesebrough. Gulu University, Gulu, Uganda

Introduction: Gulu Referral Hospital is the main government hospital
in the economic capital of Northern Uganda. Gulu district has been the
location of insurgent fighting by the Lord's Resistance Army from 1987
to 2006 and there are approximately 700 000 people living in
internally displaced persons camps. The paediatric ward has an average
of 125 admissions per month and a mortality rate of 4.4%. The overall
under-5 mortality is 23 per 100 000 in Gulu district.

Aims: To ascertain how frequently and to whom children are being
presented for ill health in an area where child mortality is high and
resources are low.

Results: Children had been presented for healthcare advice a total of
374 times in the year leading up to the admission (mean 7.5 episodes
per child, median five episodes per child). On 50% of occasions the
child was presented to a healthcare worker, most commonly a clinical
officer. On 49% of occasions the child was presented to a medication
dispensary and 1% to a traditional healer. 78% were on medication
before admission, 51% of these prescribed by a local health worker,
20% by a medicine dispenser and 20% was the parent's decision. 32% had
previously had "false tooth extraction", a practice of cutting gums to
alleviate fever and 20% scarification of the chest aimed at
alleviating breathing difficulties. 94% were fully immunised and only
one parent could think of any possible negative effects of
immunisation.

Conclusions: Medicine dispensers generally have little or no medical
training, and a lower priority is given to the training of clinical
officers than to doctors, yet it is these people who are the first
point of contact when children are unwell. Although parents were
unwilling to admit to the use of traditional healers, the use of
traditional practices of cutting skin and gums was common. However,
immunisation coverage was high and there is a general positive opinion
of immunisation.


PHLEBOTOMY TRAINING FOR PATIENT ATTENDANTS AT QUEEN ELIZABETH CENTRAL
HOSPITAL, BLANTYRE, MALAWI

1V. Walker, 1D. Rist, 2S. Lissauer, 3E. Molyneux, 1M. Goldstein.
1Birmingham Children's Hospital, Birmingham, UK, 2Heartlands Hospital,
Birmingham, UK, 3Queen Elizabeth Central Hospital, Blantyre, Malawi

Background: Great emphasis is placed on building human resource
capacity within African healthcare systems. Any attempt to reallocate
tasks from scarce professional staff to healthcare assistants is
valuable. In the Queen Elizabeth Central Hospital, the major
government teaching hospital, phlebotomy is the responsibility of
nurses who each care for 50 or more patients. A 3-week phlebotomy
teaching package was delivered in April 2008 as part of the ongoing
health link.

Aim: To adapt an existing (UK) phlebotomy training course to teach
patient attendants to undertake venepuncture and capillary sampling
safely. Five Malawi healthcare staff were identified as facilitators
to help on the course. They could then deliver the course as trainers,
enabling the phlebotomy teaching to be self-sustaining.

Methods: A DVD-based training package, donated by the National
Association of Phlebotomists, was used for the dedicated theory
sessions. This was followed by practical training with training
arms/pads then patients. All resources including black training arms
were provided by the UK partnership. 25 participants were identified
from the patient attendant cadre of staff, from the departments of
medicine, surgery, obstetrics and paediatrics. They are
non-professional with only the Junior Certificate of Education (basic
English reading and writing, basic numeracy). As part of a larger
evaluation project, participants of the phlebotomy course and those
staff trained as trainers were interviewed 6 months after the
intervention.

Results: All participants successfully completed the course
(attendance plus 10 successful venepunctures) and 6 months later all
are practising venepuncture regularly. They feel they have an enhanced
job role, which in turn improves their motivation and their enthusiasm
to learn other new skills. The ward nurses also commented that
phlebotomy performed by the patient attendants releases them to
undertake more skilled nursing tasks. The next course (December 2008)
will be run by the local facilitators, with the aim of eventually
giving venepuncture expertise to all the patient attenders in the
hospital.

Conclusions: Problem solving and adaptability has been key in making
this project a success. This intervention as part of a bigger
partnership has shown an immediate and long-term positive impact for
the healthcare staff involved and by inference the patients they are
caring for.


EMBEDDING SIDE-WARD LABORATORY TEACHING AND QUALITY ASSURANCE IN
MEDICAL STUDENT AND JUNIOR DOCTOR TRAINING, IBADAN, NIGERIA

O. Sodeinde, K. Afolabi. University College Hospital, Ibadan, Nigeria

Medical school curricula and the full registration requirements of the
Medical and Dental Council of Nigeria stipulate competencies in
side-ward laboratory usage. Due to dwindling resources, innovative
approaches were introduced to maintain adequate provisions for
necessary training, particularly microscopy of thick and thin blood
films. This procedure is a standard requirement in febrile children.
Medical students and house physicians (HP) were required to make,
stain and report on duplicate copies of such blood films, send the
other copy to the Paediatric Research Laboratory and compare the
latter report with their own. Malaria parasites, if found, were
counted against 200 or more white blood cells (WBC; thick films).
Laboratory staffing needs were met by two trained laboratory
technologists supported by technology students whose 4-6 months
industrial attachments (SIWES) are paid for centrally by the
government. High performers were invited to spend their mandatory
one-year industrial training preparatory to the higher diploma with
us. For quality assurance, 10% of slides each day were randomly
examined by a consultant, against the laboratory report produced.
Also, 1 ml blood showing severe abnormalities (eg, disseminated
intravascular coagulopathy (DIC), hyperparasitaemia) was diluted
step-wise, 1-in-10, up to 10 times with compatible normal blood and
blood films made from these dilutions. At various time points, the
results produced by trainees on these standardised films, compared
with those from the trainers, was a tool for both internal quality
assurance and for measuring trainees' progress. From 2003 to 2008,
7500 blood films (average)/year were processed and 89 SIWES students
hosted. Of these, seven came back for their one-year training. Among
63 HP, the training targets set were met by 58 in week 1 (making good
Giemsa-stained blood films); 55 in week 2 (recognition of malaria
parasites, sickle, target, burr red blood cells (RBC), "toxic" or
increased WBC, ie, >2 WBC/1000 RBC, scanty platelets); 36 in week 3
(producing reliable malaria parasite counts, ie, ±10% of trainers'
counts); 41 in week 4 (same target as week 3). HP have been able to
make timely requests for platelet infusions in DIC even before
obtaining laboratory reports. Among SIWES, these targets were reached
approximately half as often as among HP. Medical student postings were
too short for proper evaluation of the weeks 1 and 2 competences set
for them. The 50 Naira (£0.20) fee/test covers consumables, thus
assuring long-term sustainability.


"TASK-SHIFTING" TO REDUCE NEONATAL MORTALITY IN A TERTIARY REFERRAL
HOSPITAL IN A DEVELOPING COUNTRY

1H. Blencowe, 2M. Kerac. 1College of Medicine, Blantyre, Malawi, 2UCL
Centre for International Health and Development, London, UK

Background: Each year, four million neonates die worldwide,
constituting 38% of all under-5 child mortality. There is a growing
need for effective, inpatient-focused interventions: increasing
numbers of deliveries take place in a health facility and up to 45% of
neonatal mortality occurs in the first 24 h of life (before the usual
time of discharge). In many developing countries, staff shortages are
a major constraint to the delivery of high quality care. Addressing
this problem, we explore whether good clinical outcomes can be
maintained when defined tasks are "shifted" from doctors to others in
the healthcare team.

Methods: Inpatient neonatal care was previously doctor led. In 2003,
the following changes were introduced: (1) nursing auxiliary-led
Kangaroo Care for low birthweight (<2.5 kg) infants; (2) mother-led
"rooming in" on the postnatal ward for stable term babies requiring
ongoing treatment and follow-up; (3) nurse-led protocols for inpatient
care. Routinely collected outcome data on all admissions during a
3-month period in 2003 were compared with an equivalent period in
2008.

Results: Overall inpatient mortality was significantly lower in 2008
than in 2003: 124/806 (15.4%) versus 167/732 (22.8%), p = 0.0002 (see
fig). Mortality was also lower in each weight group in 2008 compared
with 2003. This was significant in infants 1000-1500 g (p = 0.002) and
infants over 2500 g (p = 0.017).


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-- 
Vern Weitzel (Mr.) BSc, BA, MA, M Env Man & Dev <vern at coombs.anu.edu.au>
<vern.weitzel at gmail.com> <vernweitzel at mac.com>

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