Objective
Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health ...centres in resource‐limited countries.
Design
Cluster randomised trial.
Setting
Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia)
Methods
Clusters were randomised to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds.
Main outcome measures
The primary outcome was a composite of maternal mortality, maternal near‐miss mortality, stillbirth, and neonatal mortality.
Results
During the 24‐month trial, 28 intervention and 28 control clusters had 24 263 and 23 160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa, and abnormal lie was within expected ranges. 9% were referred for an ultrasound‐diagnosed condition, and 71% attended the referral. The ANC (RR 1.0 95% CI 1.00, 1.01) and hospital delivery rates for complicated pregnancies (RR 1.03 95% CI 0.89, 1.20) did not differ between intervention and control clusters nor did the composite outcome (RR 1.09 95% CI 0.97, 1.23) or its individual components.
Conclusions
Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome and the individual components were not reduced.
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Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.
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Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
1 Centre for Microbiology Research, Kenya Medical Research Institute, PO Box 43640, Nairobi, Kenya
2 Department of Medical Microbiology and Genito-Urinary Medicine, University of Liverpool, Liverpool ...L69 3GA, UK
3 Department of Medical Microbiology, Kenyatta National Hospital, PO Box 20723, Nairobi, Kenya
4 Central Veterinary Investigations Laboratory, PO Private Bag, Kabete, Kenya
Correspondence Samuel Kariuki skariuki{at}kemri.org
Received 15 October 2005
Accepted 26 January 2006
In Africa, multidrug-resistant non-typhoidal salmonellae (NTS) are one of the leading causes of morbidity and high mortality in children under 5 years of age, second in importance only to pneumococcal disease. The authors studied NTS isolates from paediatric admissions at two hospitals in Nairobi, Kenya, and followed the index cases to their homes, where rectal swabs and stools from parents and siblings, and from animals in close contact, were obtained. The majority of NTS obtained from cases were Salmonella enterica serotype Typhimurium (106 out of 193; 54·9 %) and Salmonella enterica serotype Enteritidis (64; 33·2 %), a significant proportion (34·2 %) of which were multiply resistant to three or more antibiotics, including ampicillin, tetracycline, cotrimoxazole and chloramphenicol. Only 23·4 % of NTS were fully susceptible to all 10 antibiotics tested. Of the 32 NTS obtained from contacts (nine adults and 23 children) at the homes of index cases, 21 (65·6 %) isolates were similar by antibiotic-susceptibility profiles and plasmid content, and their Xba I- and Spe I-digested chromosomal DNA patterns were indistinguishable from those of the corresponding index cases. Only three out of 180 (1·7 %) samples from environmental sources, including animals, soil, sewers and food, contained NTS matching those from corresponding index cases. The carriage of NTS in an asymptomatic population was represented by 6·9 % of human contacts from 27 out of 127 homes sampled. This population of carriers may represent an important reservoir of NTS that would play a significant role in the epidemiology of community-acquired NTS bacteraemia in children.
Abbreviations: NTS, non-typhoidal salmonellae.
Prior studies have suggested that obstetrical (OB) ultrasound in low- and middle-income countries has aided in detection of high-risk conditions, which in turn could improve OB management. We are ...participating in a cluster-randomized clinical trial of OB ultrasound, which is designed to assess the effect of basic OB ultrasound on maternal mortality, fetal mortality, neonatal mortality, and maternal near-miss in 5 low-income countries. We designed a 2-week course in basic OB ultrasound, followed by 12 weeks of oversight, to train health care professionals with no prior ultrasound experience to perform basic OB ultrasound to screen for high-risk pregnancies. All patients with high-risk pregnancies identified by the trainees were referred to higher-level health facilities where fully trained sonographers confirmed the diagnoses before any actions were taken. Although there have been several published studies on basic OB ultrasound training courses for health care workers in low- and middle-income countries, quality control reporting has been limited. The purpose of this study is to report on quality control results of these trainees. Health care workers trained in similar courses could have an adjunctive role in ultrasound screening for high-risk OB conditions where access to care is limited. After completion of the ultrasound course, 41 trainees in 5 countries performed 3801 ultrasound examinations during a 12-week pilot period. Each examination was reviewed by ultrasound trainers for errors in scanning parameters and errors in diagnosis, using predetermined criteria. Of the 32,480 images comprising the 3801 examinations, 94.8% were rated as satisfactory by the reviewers. There was 99.4% concordance between trainee and reviewer ultrasound diagnosis. The results suggest that trained health care workers could play a role in ultrasound screening for high-risk OB conditions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Whether facility-based implementation of Helping Babies Breathe (HBB) reduces neonatal mortality at a population level in low and middle income countries (LMIC) has not been studied. Therefore, we ...evaluated HBB implementation in this context where our study team has ongoing prospective outcome data on all pregnancies regardless of place of delivery.
We compared outcomes of birth cohorts in three sites in India and Kenya pre-post implementation of a facility-based intervention, using a prospective, population-based registry in 52 geographic clusters. Our hypothesis was that HBB implementation would result in a 20 % decrease in the perinatal mortality rate (PMR) among births ≥1500 g.
We enrolled 70,704 births during two 12-month study periods. Births within each site did not differ pre-post intervention, except for an increased proportion of <2500 g newborns and deliveries by caesarean section in the post period. There were no significant differences in PMR among all registry births; however, a post-hoc analysis stratified by birthweight documented improvement in <2500 g mortality in Belgaum in both registry and in HBB-trained facility births. No improvement in <2500 g mortality measures was noted in Nagpur or Kenya and there was no improvement in normal birth weight survival.
Rapid scale up of HBB training of facility birth attendants in three diverse sites in India and Kenya was not associated with consistent improvements in mortality among all neonates ≥1500 g; however, differential improvements in <2500 g survival in Belgaum suggest the need for careful implementation of HBB training with attention to the target population, data collection, and ongoing quality monitoring activities.
The study was registered at ClinicalTrials.gov: NCT01681017 .
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
In high-resource settings, obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve ...obstetric care. Whether or not ultrasound use will improve care and ultimately pregnancy outcomes in low-resource settings is unknown.
This multi-country cluster randomized trial will assess the impact of antenatal ultrasound screening performed by health care staff on a composite outcome consisting of maternal mortality and maternal near-miss, stillbirth and neonatal mortality in low-resource community settings. The trial will utilize an existing research infrastructure, the Global Network for Women's and Children's Health Research with sites in Pakistan, Kenya, Zambia, Democratic Republic of Congo and Guatemala. A maternal and newborn health registry in defined geographic areas which documents all pregnancies and their outcomes to 6 weeks post-delivery will provide population-based rates of maternal mortality and morbidity, stillbirth, neonatal mortality and morbidity, and health care utilization for study clusters. A total of 58 study clusters each with a health center and about 500 births per year will be randomized (29 intervention and 29 control). The intervention includes training of health workers (e.g., nurses, midwives, clinical officers) to perform ultrasound examinations during antenatal care, generally at 18-22 and at 32-36 weeks for each subject. Women who are identified as having a complication of pregnancy will be referred to a hospital for appropriate care. Finally, the intervention includes community sensitization activities to inform women and their families of the availability of ultrasound at the antenatal care clinic and training in emergency obstetric and neonatal care at referral facilities.
In summary, our trial will evaluate whether introduction of ultrasound during antenatal care improves pregnancy outcomes in rural, low-resource settings. The intervention includes training for ultrasound-naïve providers in basic obstetric ultrasonography and then enabling these trainees to use ultrasound to screen for pregnancy complications in primary antenatal care clinics and to refer appropriately.
Clinicaltrials.gov (NCT # 01990625).
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
SETTING: Risk factors for mortality in hospitalized patients with community-acquired pneumonia (CAP) are well known. There are limited data on prognostic indicators among out-patients.OBJECTIVE: To ...compare the clinical presentation, outcome and prognostic factors for clinical improvement
in human immunodeficiency virus (HIV) infected and non-HIV-infected out-patients with CAP.METHODOLOGY: Adults in Nairobi with CAP were treated with erythromycin as first-line therapy. Clinical symptoms were evaluated using a validated CAP-related symptom score (CSS). Clinical improvement
was defined as reduction of baseline CSS by ≥50%.RESULTS: Of 531 adults enrolled with CAP, 422 (79.5%) completed follow-up. Participants had a mean age (±SD) of 33.7 ± 11.4 years, 274 (51.6%) were male and 193 (37%) were HIV-seropositive with a higher baseline CSS (27
vs. 25, P < 0.006). Overall, 196 of 422 (46%) had clinical improvement by 28 days. Factors independently associated with a longer time to clinical improvement included not being married (adjusted hazard ratio aHR 0.66, 95%CI 0.48-0.92) and higher baseline CSS (aHR 1.05, 95%CI
1.03-1.06).CONCLUSIONS: HIV-infected and non-infected patients with CAP responded similarly to out-patient treatment, but HIV-infected patients were more likely to present with severe symptoms. Baseline CSS and marital status were predictive of time to clinical improvement.
Over the last decade there has been a steady increase in the proportion of multidrug resistance among non-typhoidal salmonellae (NTS) isolated from adult patients with bacteraemia in Kenya. The ...prevalence of NTS multiply resistant to all commonly available drugs including ampicillin, streptomycin, co-trimoxazole, chloramphenicol and tetracycline rose from 31% in 1994 to 42% at present, with concomitantly higher MICs of each drug. Resistance is encoded on large self-transferable 100–110
kb plasmids. Pulsed field gel electrophoresis of
XbaI and
SpeI digested chromosomal DNA revealed three main digest patterns for
Salmonella enterica serotype Typhimurium and two main patterns for
Salmonella enterica serotype Enteritidis. Although the genotypes of NTS remained fairly stable over the last decade, the large increase in MICs of all commonly used drugs and increased MICs of ciprofloxacin, poses a major challenge for treatment of invasive NTS infection.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To determine the antimicrobial susceptibility patterns of Streptococcus pneumoniae and Haemophilus influenzae, two bacterial pathogens commonly associated with community-acquired pneumonia.
...Cross-sectional study.
Bacterial isolates were obtained from adults suspected to have community-acquired pneumonia and who sought treatment at two city council clinics in Nairobi, Kenya. Susceptibility to antimicrobial agents was performed using a microdilution broth method, according to the criteria set by the National Committee for Clinical Laboratory Standards.
A total of 277 S. pneumoniae and 58 H. influenzae were obtained from 536 adults examined in the period January 1998 to December 1999. Of the 277 S. pneumoniae, only 56.7% were susceptible to penicillin and 7.6% of strains were resistant to two or more antimicrobial agents. Of the 58 H. influenzae strains, 91.4% were sensitive to ampicillin, with 6.8% resistant to two or more antimicrobial agents. 8.6% were beta-lactamase producers and accounted for the entire ampicillin-resistant population.
The prevalence of resistance to penicillin and other commonly used antibiotics among pneumococci is high and the large number of multi-resistant strains among H. influenzae is a cause for concern. The prudent use of antibiotics in treatment of pneumonia and other infections should be advocated to minimise spread of resistance.
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