Acute bacterial meningitis in children admitted to the Queen Elizabeth Central Hospital Blantyre, Malawi in 1996-97.

In order to design appropriate interventioos, we collected clinical and demographic data prospectively on all children aged one day to 14 years admitted with a diagnosis of bacterial meningitis (BM) from April 1st 1996 to March 31st 1997 to the Queen Elizabeth Central Hospital (QECH), Blantyre Malawi. During the study period 267 children (2.7% of all paediatric admissions) were found to have BM; 83% were under 5 years of age, 61 % under one year and 23% under one month. The most common causative organisms in the post neonatal period (n = 206) were Streptococcus pneumoniae (27%), Haemophilus influenzae type b (Hib) 21 %, and Salmonella typhimurium (6%). In the neonatal group «I month, n = 61) the most common causes were Streptococcus agalactiae (23%), S. typhimurium (15%), S. pneumoniae (11. 5%) and other gram negative rods (11.5%). Nineteen of 21 salmonella infections were in children under one year of age and all S. agalactiae were in infants under three months. There was delay on presentation: the average length of fever was 4.6 days, 39.5% had convulsed prior to arrival and 57% had an altered level of consciousness. An initial diagnosis of malaria had probably contributed to the delay in 22.5% , (42 of 186 tested). Forty eight percent were < 80% weight for age, with 18% < 60 % weight for age. The overall mortality was 40%. The outcome was worst in salmonella infections, particularly neonatal salmonella BM with a case fatality rate (CFR) of 89% (8 of 9 cases). Coma on presentation worsened prognosis (mortality 64% if Blantyre Coma Score <3, 26% if > 3). Fifteen percent of survivors had sequelae on discharge. Twenty percent of Hib isolates were resistant to chloramphenicol, but all salmonellae were sensitive. Five percent of S. pneumoniae were resistant to penicillin and 8% to chloramphenicol. Earlier access to adequate health care and awareness of BM in a malaria endemic area would reduce mortality and morbidity. Vaccination against Hib infection would have reduced death by 18 (17%) and prevented sequelae in 7

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

Establishing the impact of powerful AGN on their host galaxies

Establishing the role of active galactic nuclei (AGN) during the formation of galaxies remains one of the greatest challenges of galaxy formation theory. Towards addressing this, we summarise our recent work investigating: (1) the physical drivers of ionised outflows and (2) observational signatures of the impact by jets/outflows on star formation and molecular gas content in AGN host galaxies. We confirm a connection between radio emission and extreme ionised gas kinematics in AGN hosts. Emission-line selected AGN are significantly more likely to exhibit ionised outflows (as traced by the [O III] emission line) if the projected linear extent of the radio emission is confined within the spectroscopic aperture. Follow-up high resolution radio observations and integral field spectroscopy of 10 luminous Type 2 AGN reveal moderate power, young (or frustrated) jets interacting with the interstellar medium. We find that these sources live in highly star forming and gas rich galaxies. Additionally, by combining ALMA-derived dust maps with integral field spectroscopy for eight host galaxies of z~2 X-ray AGN, we show that H-alpha emission is an unreliable tracer of star formation. For the five targets with ionised outflows we find no dramatic in-situ shut down of the star formation. Across both of these studies we find that if these AGN do have a negative impact upon their host galaxies, it must be happening on small (unresolved) spatial scales and/or an observable galaxy-wide impact has yet to occur.Comment: Invited Contribution to IAU Symposium 359 (T. Storchi-Bergmann, R. Overzier, W. Forman & R. Riffel, eds.

Entomological indices of malaria transmission in Chikhwawa district, Southern Malawi

Abstract Background Although malaria is highly prevalent throughout Malawi, little is known of its transmission dynamics. This paper describes the seasonal activity of the different vectors, human biting indices, sporozoite rates and the entomological inoculation rate in a low-lying rural area in southern Malawi. Methods Vectors were sampled over 52 weeks from January 2002 to January 2003, by pyrethrum knockdown catch in two villages in Chikhwawa district, in the Lower Shire Valley. Results In total, 7,717 anophelines were collected of which 55.1% were Anopheles gambiae sensu lato and 44.9% were Anopheles funestus. Three members of the An. gambiae complex were identified by PCR: Anopheles arabiensis (75%) was abundant throughout the year, An. gambiae s.s. (25%) was most common during the wet season and Anopheles quadriannulatus occurred at a very low frequency (n=16). An. funestus was found in all samples but was most common during the dry season. Anopheles gambiae s.s. and An. funestus were highly anthropophilic with human blood indices of 99.2% and 96.3%, respectively. Anopheles arabiensis had fed predominantly on humans (85.0%) and less commonly on cattle (10.9%; 1.2% of blood meals were of mixed origin). Plasmodium falciparum (192/3,984) and Plasmodium malariae (1/3,984) sporozoites were detected by PCR in An. arabiensis (3.2%) and An. funestus (4.5%), and in a significantly higher proportion of An. gambiae s.s. (10.6%)(pP. falciparum sporozoite rate was 4.8%, resulting in estimated inoculation rates of 183 infective bites/ person per annum, or an average rate of ~15 infective bites/person/month. Conclusions The results demonstrate the importance of An. gambiae s.s., An. arabiensis and An. funestus in driving the high levels of malaria transmission in the south of Malawi. Sustained and high coverage or roll out of current approaches to malaria control (primarily insecticide-treated bed nets and indoor residual house spraying) in the area are likely to reduce the observed high malaria transmission rate and consequently the incidence of human infections, unless impeded by increasing resistance of vectors to insecticides.</p

Review of Health Sector Services Fund Implementation and Experience

The Health Sector Services Fund (HSSF) is an innovative scheme established by the Government of Kenya (GOK) to disburse funds directly to health facilities to enable them to improve health service delivery to local communities. HSSF empowers local communities to take charge of their health by actively involving them through the Health Facility Management Committees (HFMCs) in the identification of their health priorities and in planning and implementation of initiatives responsive to the identified priorities. Following a successful pilot of a similar mechanism, the strategy was scaled up nationwide, starting in 2010. Following the recent general election in Kenya, dramatic changes to the health system are being considered and introduced, including devolution of government functions to 47 semi-autonomous counties, the merging of the two ministries of health, and the abolition of user fees at health centres and dispensaries. Given the experience of nearly 3 years of HSSF implementation, and the context of these important changes in the organisation of health service delivery, a review of experiences to date with HSSF and key issues to consider moving forward is timely. The overall goal of HSSF is to generate sufficient resources for providing adequate curative, preventive and promotive services at community, dispensary and health centre levels, and to account for the resources in an efficient and transparent manner. HSSF can cover items such as facility operations and maintenance, refurbishment, support staff, allowances, communications, utilities, non-drug supplies, fuel and community based activities. DANIDA and the World Bank are currently partnering with the MOPHS in supporting the HSSF’s phased implementation which began in October 2010 with public health centres, and public dispensaries in July 2012. Following a facility stakeholder’s forum, HFMCs should develop annual work plans (AWPs) and quarterly implementation plans (QIPs). HSSF resources are credited directly to each designated facility’s bank account every quarter and to the District Health Management Team (DHMT): KSH 112,000 (1,339 USD) for health centres, KSH 27,500 (327 USD) for dispensaries and 131,500 (1,565 USD) for DHMTs. Other funds available to the facility, such as user fee revenue, and grants and donations received locally, should be banked in the same account, and managed and accounted for together with HSSF funds from national level. All funds should be managed by the Health Facility Management Committee (HFMC) which includes community representatives, according to the financial guidelines approved by the Ministry of Health (MOH). Funds can only be spent on receipt of an Authority to Incur Expenditure (AIE) from national level. Facilities must then account for funds using monthly and quarterly financial reports, and expenditures are recorded in a specific software called Navision. Facility level supervision and support is provided by the DHMT and county based accountants (CBAs) hired specifically for HSSF; and at national level HSSF oversight is provided by the National Health Sector Committee. This review had the following objectives: 1. To describe the process of HSSF implementation to date, including facilities covered, funds disbursed, and activities undertaken. 2. To review evidence on the experience with HSSF implementation 3. To identify key issues including devolution for consideration in future planning around HSSF These objectives have been addressed through review of policy documents, administrative reports, and research studies related to HSSF; and interviews with key stakeholders in MOPHS, DANIDA and the World Bank, to obtain updates on HSSF implementation and experience

Poor Potential Coverage for 7-Valent Pneumococcal Conjugate Vaccine, Malawi

Streptococcus pneumoniae infections can be prevented by using new conjugate vaccines, but these vaccines have limited serogroup coverage. We report the first serogrouping data from carried and invasive isolates obtained from children and adults in Malawi. The 7-valent vaccine would cover 41% of invasive isolates from children and 25% from adults. A 9-valent vaccine, including types 1 and 5, would cover 66% of invasive isolates from children and 55% from adults

Bacterial Meningitis in Malawian Adults, Adolescents, and Children During the Era of Antiretroviral Scale-up and Haemophilus influenzae Type b Vaccination, 2000-2012

Background We documented bacterial meningitis trends among adults and children presenting to a large teaching hospital in Malawi during introduction of Haemophilus influenzae type b (Hib) vaccination and the rollout of antiretroviral therapy (ART). Methods We analyzed data from 51 000 consecutive cerebrospinal fluid (CSF) samples obtained from adults, adolescents, and children with suspected meningitis admitted to the Queen Elizabeth Central Hospital, Blantyre, Malawi, between 2000 and 2012. Results There was a significant decline in the total number of CSF isolates over 12 years (incident rate ratio [IRR], 0.93; 95% CI, .92–.94; P < .001). This decline was entirely in children aged <5 years (IRR, 0.87; 95% CI, .85–.88; P < .001) and coincided with the introduction of Hib vaccination. The number of adult isolates has remained unchanged (IRR, 0.99; 95% CI, .97–1.0; P = .135) despite rapid scale-up of ART provision. In children aged <5 years, Streptococcus pneumoniae, nontyphoidal salmonellae (NTS), and Hib were the most frequently isolated pathogens, and have declined over this time period. Streptococcus pneumoniae was the most frequently isolated pathogen in older children and adults. Estimated incidence of bacterial meningitis in 2012 was 20 per 100 000 cases in children aged <14 years, 6 per 100 000 adolescents, and 10 per 100 000 adults. Conclusions Rates of bacterial meningitis have declined in children, but not adults, coinciding with the introduction of Hib vaccination. The highly successful rollout of ART has not yet resulted in a reduction in the incidence in adults where the burden remains high. Long-term surveillance of bacterial meningitis outside of the epidemic “meningitis belt” in Africa is essential

A New Large-Well 1024x1024 Si:As Detector for the Mid-Infrare

We present a description of a new 1024x1024 Si:As array designed for ground-based use from 5 - 28 microns. With a maximum well depth of 5e6 electrons, this device brings large-format array technology to bear on ground-based mid-infrared programs, allowing entry to the megapixel realm previously only accessible to the near-IR. The multiplexer design features switchable gain, a 256x256 windowing mode for extremely bright sources, and it is two-edge buttable. The device is currently in its final design phase at DRS in Cypress, CA. We anticipate completion of the foundry run in the beginning of 2006. This new array will enable wide field, high angular resolution ground-based follow up of targets found by space-based missions such as the Spitzer Space Telescope and the Widefield Infrared Survey Explorer (WISE).Comment: 8 pages, 9 figures, 2005 San Diego SPI