Musings on malaria morbidity and mortality after the new Mosquirix® vaccine

There are some facts relating to the new malaria vaccine (Mosquirix® or RTS,S/AS01) recently introduced in Ghana, which need to be more widely known. Contrary to expectations based on mathematical modelling and on the vaccine’s effect on clinical malaria and severe malaria, mortality was not reduced in children receiving the Mosquirix® vaccine in the phase 3 trial.1 This (surprising) result has been attributed to the fact that mortality was reduced in both the vaccinated and unvaccinated children due to better implementation of malaria control measures such as use of bed nets and prompt treatment of malaria.2 The startling implication of thisfinding is that when the existing malaria control measures are implemented more effectively, the vaccine in its current form does not offer any measurable mortality advantages.This means that if there were a willingness to implement malaria control measures intensively, there would be no need to expose our children to the unknown effects of a new vaccine

Admissions and mortality over a 5-year period in a limited-resource neonatal unit in Ghana

Objective: To review admissions and deaths at the neonatal intensive care unit (NICU) of the Korle Bu Teaching Hospital (KBTH), Ghana from 2011 to 2015, for the purposes of documentation of outcomes and identification of areas for improvement.Design: A retrospective descriptive study of NICU Admissions & Discharges from 2011 to 2015. All data in the NICU Admissions & Discharge books were transferred into a spreadsheet and analysed.Setting – The NICU of KBTH provides secondary and tertiary care for premature and critically ill term babies in the southern half of Ghana.Results: Over the 5-year period, 9213 babies were admitted to the NICU. Admission weights ranged from 300 to 6700g with median of 2400g. Overall mortality rate was 19.2%. Mortality rates were progressively and significantly higher in babies with lower admission weights and earlier gestations.Conclusions: We report a high NICU mortality rate of 19.2%, compared to the worldwide range of 3.1% to 29%. This wide range of outcomes is attributable to differences in the severity of illness of patients and to the organisation of resources devoted to obstetric and neonatal care. To substantially improve perinatal and neonatal outcomes, there is a need for wider coverage and better quality of health care; and to consider rationing of care. Complex interventions are necessary to improve outcomes, not just an increase in the allocation of particular resources.Keywords: Intensive Care, Neonatal; developing countries; mortality rateFunding: None declare

Audit of antenatal steroid use in mothers of preterms admitted to a neonatal intensive care unit in Ghana.

Background: Antenatal corticosteroids (ACS) are established as an effective method of reducing preterm morbidity and mortality. At the Korle Bu Teaching Hospital (KBTH), a tertiary referral centre in Ghana, it is recommended that a course of ACS should be given to mothers before delivery between 24 weeks to 34 weeks gestation.Objectives: The study was performed primarily to determine the level of adherence to guidelines on administration of ACS.Methods: All babies with gestational ages up to 34 weeks admitted to the neonatal unit (NICU) during the period of the study were eligible for inclusion.Results: There were 214 eligible admissions during the study period, of which 93 babies (43%) were studied due to poor access to medical records. Dexamethasone was the only steroid used, and mothers of 65 (70%) of the 93 babies received at least one dose; 17 (18%) received only one dose, 35 (38%) - 2 doses, 9 (10%) – 3 doses, and 4 (4%) - 4doses.Conclusions: This study has shown a low uptake of antenatal corticosteroids, similar to other low-income and middle-income countries. To improve preterm survival and morbidity, there is an urgent need to increase the use of corticosteroids before preterm deliveries in Ghana and other low-income and middle-income countries.Funding: Not indicatedKeywords: Antenatal corticosteroids, prematurity, neonatal intensive care, audit, low-income countries

Subcutaneous basidiobolomycosis: A Case Report

Basidiobolomycosis is an uncommon chronic deep fungal infection in which gradually enlarging granulomas form, usually in the subcutaneous fat tissues of the limbs, chest or trunk of immunocompetent hosts, primarily children and young adults. It is caused by the fungus Basidiobolus ranarum. Definitive diagnosis is by microscopy and histopathology.Effective treatments include ketoconazole, itraconazole, potassium iodide and co-trimoxazole.A 3 year old girl presented with ulcerations on the right thigh for one month, and painful swelling of the right leg and right buttock for six months. The right lower limb and vulva were swollen, tender and hard with hyperpigmentation and inguinal lymphadenopathy.She had severe anaemia, eosinophilia and negative serology for HIV I and II. Histopathological examination showed a dermal chronic granulomatous infiltrate with fungal hyphae and yeast forms suggestive of Basidiobolus ranarum.There was marked reduction in right leg size and inguinal lymphadenopathy after several weeks of oral itraconazole, and complete healing of ulcers after 10 weeks.The purpose of this report is to increase awareness of this disfiguring condition which is treatable but, if not correctly diagnosed, could result in inappropriate interventions such as amputation and anti-coagulant therapy.Funding: None declaredKeywords: Deep fungal infection, basidiobolomycosis, itraconazole, chronic ulcer, leg swellin

Occurrence of neonatal hypothermia and associated risk factors among low birth weight (LBW) infants in Accra, Ghana

# Background Neonatal hypothermia is a prominent issue in low-resource settings. Preterm and low birth weight (LBW) infants are at increased risk for developing hypothermia. If left untreated, hypothermia can lead to hypoxia, sepsis, hypoglycemia, apnea, and poor weight gain in neonates, contributing to neonatal morbidity and mortality. Identifying risk factors for neonatal hypothermia is important, especially in low-resource settings, where the burden of neonatal mortality is highest. The study sought to describe the distribution of neonatal hypothermia and examine risk factors associated with neonatal hypothermia among LBW infants admitted to Korle-Bu Teaching Hospital in Accra, Ghana. # Methods Infants in the neonatal intensive care unit (NICU) at Korle-Bu Teaching Hospital, who were less than 28 days old, weighing less than \<2,500 grams, and clinically stable, were enrolled. Infants of mothers under 18 years old and those expected to be discharged within 24 hours were excluded from the study. A standardized questionnaire was administered to collect information on the mother, infant, pregnancy, and birth characteristics. Axillary temperature readings were taken every 4 hours over a 24-hour monitoring period and during hypothermic events detected by the continuous temperature monitoring bracelet. Univariate and multivariate linear regression analyses with generalized estimating equations were used to examine risk factors associated with temperature. # Results Of the 254 infants included in the analysis, 42.1% were male, 49.6% were very LBW (\<1,500 grams), and 94.1% were preterm (\<37 weeks). Of the 1,948 temperature readings, 44.5% were hypothermic (\<36.5^o^C). Hypothermia occurred in 85.8% of infants during the 24-hour monitoring period. Multivariate linear regression demonstrated that being very LBW, having no skin-to-skin contact immediately after birth, not being wrapped or treated in an incubator at the time of temperature, and mixed feeding (compared to exclusive breastfeeding) were associated with lower neonatal temperatures. # Conclusions Neonatal hypothermia was common among infants admitted to the NICU. The findings highlight the importance of thermal practices such as wrapping, exclusive breastfeeding and skin-to-skin contact. Increased education to promote thermal care is needed

Characteristics of HIV-2 and HIV-1/HIV-2 Dually Seropositive Adults in West Africa Presenting for Care and Antiretroviral Therapy: The IeDEA-West Africa HIV-2 Cohort Study.

HIV-2 is endemic in West Africa. There is a lack of evidence-based guidelines on the diagnosis, management and antiretroviral therapy (ART) for HIV-2 or HIV-1/HIV-2 dual infections. Because of these issues, we designed a West African collaborative cohort for HIV-2 infection within the framework of the International epidemiological Databases to Evaluate AIDS (IeDEA).We collected data on all HIV-2 and HIV-1/HIV-2 dually seropositive patients (both ARV-naive and starting ART) and followed-up in clinical centres in the IeDEA-WA network including a total of 13 clinics in five countries: Benin, Burkina-Faso Côte d'Ivoire, Mali, and Senegal, in the West Africa region.Data was merged for 1,754 patients (56% female), including 1,021 HIV-2 infected patients (551 on ART) and 733 dually seropositive for both HIV-1 and HIV 2 (463 on ART). At ART initiation, the median age of HIV-2 patients was 45.3 years, IQR: (38.3-51.7) and 42.4 years, IQR (37.0-47.3) for dually seropositive patients (p = 0.048). Overall, 16.7% of HIV-2 patients on ART had an advanced clinical stage (WHO IV or CDC-C). The median CD4 count at the ART initiation is 166 cells/mm(3), IQR (83-247) among HIV-2 infected patients and 146 cells/mm(3), IQR (55-249) among dually seropositive patients. Overall, in ART-treated patients, the CD4 count increased 126 cells/mm(3) after 24 months on ART for HIV-2 patients and 169 cells/mm(3) for dually seropositive patients. Of 551 HIV-2 patients on ART, 5.8% died and 10.2% were lost to follow-up during the median time on ART of 2.4 years, IQR (0.7-4.3).This large multi-country study of HIV-2 and HIV-1/HIV-2 dual infection in West Africa suggests that routine clinical care is less than optimal and that management and treatment of HIV-2 could be further informed by ongoing studies and randomized clinical trials in this population